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v^ 



SAJOUS'S 

Analytic Cyclopedia 



OF 



Practical Medicine 



BY 



CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D. 

ASSISTED BY 

LOUIS T. de M. SAJOUS, B.S., M.D. 

WITH THE ACTIVE CO-OPERATION OF OVER 

ONE HUNDRED ASSOCIATE EDITORS 



NINTH REVISED EDITION 



1[llustrate& witb jfulUpaoe IbalMone an& Color: plates 
an& appropriate Cuts in tbe Ueit 



Volume Eight 



59 ^^3 




PHILADELPHIA 

F. A. DAVIS COMPANY. PUBLISHERS 

1922 



COPYRIGHT. 1022 

BY 

K. A. DAVIS COMPANY 



Copyrigbl, Ureal Urltaiii. All Rights Reserved 



v/ 



PRINTED IN US. A. 

PRESS OF 

F. A. DAVIS COMPANY 

PHILADELPHIA. PA. 



CONTRIBUTORS TO VOLUME VIII. 



W. WAYNE BABCOCK, A.M., M.D., 

Professor of Surgery, Temple University Medical School ; Surgeon in Chief 
to the Samaritan and Garrctson Hospitals, 

PurLADELPHIA, Pa. 

REGINALD IT. SAYRE, M.D., 
Professor of Orthopedic Surgery, University and Eellevue Hospital Medical College, 

New York City. 

LEONARD FREEMAN, M.D., 
Professor of Surgery, University of Colorado School of Medicine, 

Denver, Colo. 

ERNEST LAPLACE, M.D., lA.A)., 
Professor of Surgery, University of Pennsylvania Graduate Medical School, 

Philadelphia, Pa. 

HENRY T. BYFORD, M.D., 

Professor of Gynecology and Clinical Gynecology, University of 

Illinois College of Medicine. 

Chicago, III. 

ALFRED C. WOOD, M.D., 
Assistant Professor of Surgery, University of Pennsylvania Medical School, 

Philadelphia, Pa. 

ANTHONY BASSLER, M.D., 
Clinical Professor of Medicine, New York Polyclinic Medical School, 

Xew York City. 

WM. BROADDUS PRITCHARD. M.D.. 
Professor of Neurology, New York Polyclinic Medical School, 

New York City. 

EDWARD JACKSON, M.D., 
Professor of Ophthalmology, University of Colorado School of Medicine, 

Denver, Colo. 

G. FRANK LYDSTON, M.D., 

Professor of Genitourinary Surgery, Illinois State University, 

Chicago, III. 

E. D. BONDURANT, M.D., 
Professor of Mental and Nervous Diseases, University of Alabama School of Medicine, 

Mobile, Ala. 

(iii) 



iv COXTRIBUTORS TO VOLUME VIII. 

H. BROOKER MILLS, M.D., 

Professor of Pediatrics, Temple University Medical School ; Visiting Physician 

to the Philadelphia Hospital for Contagious Diseases, 

Philadelphia, Pa. 

MYER SOLIS-COHEN, M.D.. 

Visiting Physician to Home for Consumptives, Chestnut Hill, and Pediatrist 
to Jewish Hospital and Eagleville Sanatorium for Consumptives, 

Philadelphia, Pa. 

J. MADISON TAYLOR, A.M., M.D., 
Professor of Physical Therapeutics, Temple University Medical School, 

Philadelphia, Pa. 

MARTIN E. REHFUSS, M.D., 

Associate in Gastrological Research, Chemical Department, and Instructor 

in Medicine, Jeflferson Medical College, 

Philadelphia, Pa. 

A. ROBIN, M.D., 

Bacteriologist of the Wilmington City Water Department; formerly Pathologist and 

Bacteriologist of the Delaware State Board of Health. 

Wilmington, Del. 

GUSTAVUS C. BIRD, M.D., 
Professor of Rontgenology and Radiotherapy, Temple University Medical School, 

Philadelphia, Pa. 

ANDREW F. CURRIER, M.D., 
Mt. Vernon, N. Y. 

C. SUMNER WITHERSTINE, M.S., M.D., 
Lecturer on Pharmacology, Temple University Medical School, 

Philadelphia, Pa. 

F. LEVISON, M.D., 

Formerly Officer of Health, 

Copenhagen, Denmark. 

C. E. deM. SAJOUS, M.D., LL.D., Sc.D., 

Professor of Endocrinology in the University of Pennsylvania Graduate Medical 
School and Professor of Therapeutics in Temple University Medical School, 

Philadelphia, Pa. 

L. T. deM. SAJOUS, B.S., M.D., 

Associate Professor of Pharmacolog>' in Temple University Medical School and Instructor 

of Endocrinology in the University of Pennsylvania Graduate Medical School, 

Philadelphia, Pa. 



CONTENTS OF EIGHTH VOLUME. 



PAGE 

Rheumatism 1 

Rheumatic Fever 1 

Symptoms 1 

Complications 3 

Diagnosis 6 

Secondary Infectious Arthritis .... 7 

Acute Osteomyelitis 7 

Gout 7 

Etiology 7 

Pathology 10 

Prognosis 11 

Treatment 12 

Muscular Rheumatism 21 

Symptoms 21 

Etiology and Pathology 22 

Treatment 2Z 

Gonococcal (Gonorrheal) Rheumatism. 26 

Symptoms 26 

Diagnosis 27 

Etiology 27 

Prognosis 27 

Treatment 27 

Rheumatoid Arthritis. See Joints, Sur- 
gical Diseases of. 
Rhigolene. See Petroleum. 
Rhinitis and Other Nasal Disorders. See 
Index. 

Rhubarb 29 

Preparations and Doses 29 

Poisoning by Rhubarb 30 

Therapeutics 30 

Rhus Poisoning. See Dermatitis Vene- 
nata. 
Ribs, Diseases and Injuries of. See Index. 
Rickets. See Bones, Diseases of. 
Riga's Disease. See Mouth, Lips, and 

Jaws, Diseases of. 
Riggs's Disease; Pyorrhea Alveolaris 

(Spongy Gums) 30 

Definition 30 

Symptoms 30 

Diagnosis 31 

Etiology 31 

Pathology 23 

Treatment 33 

Ringworm. See Trichophytosis. 
Rochelle Salts. See Potassium and 

Sodium Tartrate. 
Rocky Mountain Spotted Fever (Tick 

Fever) 35 

Symptoms 36 

Incubation 36 

Fever 36 

Circulation 36 

Eruption Z7 

Gastrointestinal Tract 27 

Urinary Tract 37 



PAGE 

Rocky Mountain Spotted Fever (Tick 
Fever), Symptoms {continued). 

Respiratory Tract 27 

Nervous System 27 

Diagnosis 27 

Etiology 38 

Prognosis 38 

Treatment 38 

Rubella 39 

Synonyms 39 

Definition 39 

Period of Incubation 39 

Symptoms 40 

Etiology 42 

Complications and Sequelae 43 

Prognosis 43 

Treatment 43 

Rubeola. See Measles. 

Rue 43 

Preparations and Doses 43 

Physiological Action 44 

Therapeutic Uses 44 

Saccharin 44 

Physiological Effects 44 

Poisoning by Saccharin 45 

Treatment of Poisoning 45 

Therapeutic Uses 45 

Salicylic Acid, The Salicylates, and 

Salicin 45 

Preparations and Dose 45 

Unofficial Preparations 47 

Incompatibilities 49 

Modes of Administration 49 

Contraindications 52 

Physiological Action 52 

Untoward EflFects and Poisoning 53 

Treatment of Poisoning 54 

Therapeutics 55 

General Uses 55 

Local Uses 58 

Saline Infusion. See Infusions, Saline . 59 

Salivary Glands, Diseases of 60 

Xerostoma (Dry Mouth) 60 

Symptoms 60 

Etiology and Pathology 60 

Treatment 60 

Ptyalism '. 60 

Treatment 60 

Ptyalism 60 

Salivary Calculus 60 

Treatment 61 

Tumors of the Salivarv Glands 61 

Cvsts ". 61 

Tumors of the Parotid 61 

Tumors of the Maxillary Gland .... 61 

Parotitis 62 

Definitions 62 

(v) 



VI 



CONTENTS. 



PAGE 

Salivary Glands, Diseases of, Parotitis 
(coniiiiucd). 

Traumatic Parotitis 62 

Infectious Parotitis 62 

1. Mumps 62 

Incubation 63 

Symptoms 63 

Diagnosis 65 

Etiology 65 

Pathology 65 

Complications and Sequelae . . 65 

Prognosis 67 

Treatment 67 

2. Metastatic or Symptomatic Par- 

otitis 68 

Symptoms 68 

Pathology 68 

Prognosis 69 

Treatment 69 

Salol. See Salicylic Acid. 

Salophen 69 

Dose and Physiological Action 69 

Therapeutics 69 

Salpingitis. See Ovaries and Fallopian 

Tubes, Diseases of. 
Salt. See Sodium. 
Salvarsan. See Dioxydiamidoarseno- 

benzol. 

Sandalwood and Oil of Sandalwood.... 70 

Physiological Action and Dose 70 

Therapeutics 70 

Sanguinaria 70 

Preparations and Doses 70 

Physiological Action 71 

Treatment of Poisoning 71 

Therapeutic Action 71 

Santonica and Santonin 71 

Preparations and Doses 71 

Physiological Action 71 

Poisoning by Santonin 71 

Therapeutic Uses 72 

Sapremia. See Wounds, Septic, and 

Sepsis. 
Sarcoma. See Cancer. 

Sarsaparilla 72 

Preparations and Doses 72 

Therapeutic Uses 72 

Scabies 73 

Definition 73 

Symptoms 73 

Etiology 73 

Treatment 73 

Scammonia 74 

Preparations and Doses 74 

Physiological Action 74 

Therapeutic Uses 74 

Scarlet Fever 75 

Definition 75 

Symptoms 75 

Ordinary Tvpe 75 

Mild Type " 77 

Severe Type 78 

Malignant Type 78 

Surgical Scarlet Fever 79 

Diagnosis and Etiology 79 

Transmission 82 

Period of Incubation 83 



PAGE 

Scarlet Fever, Diagnosis and Etiology 
{roiitinued). 

Period of Infection 84 

Pathology 84 

Complications and Sequelae 84 

Angina 84 

Otitis 85 

Adenitis and Cellulitis 85 

Joint Lesions 85 

Nephritis 85 

Pneumonia 86 

Endocarditis and Pericarditis .... 86 

Nervous Symptoms 86 

Serous Membranous Involvement. 86 

Superficial Gangrene 86 

Prognosis 86 

Prophylaxis 87 

Treatment 89 

Schlammfieber 94 

Sciatica. See Nerves, Peripheral, Dis- 
eases of. 

Scleroderma 94 

Definition 94 

Varieties 94 

Symptoms 94 

Diagnosis 94 

Etiology 95 

Prognosis 95 

Treatment 95 

Sclerosis. See Index. 
Scoliosis. See Spine, Diseases and In- 
juries of. 

Scoparius and Sparteine 95 

Preparations and Doses 96 

Physiological Action 96 

Therapeutic Uses 97 

Scopolamine (Hyoscine) and Scopola . . 98 

Preparations and Dose 99 

Incompatibilities 99 

Modes of Administration 99 

Physiological Action 99 

Absorption and Elimination 100 

Untoward Effects and Poisoning .... 100 

Treatment of Poisoning 101 

Therapeutics 102 

As Sedative to the Central Nervous 

System 102 

As Mydriatic and Cycloplegic 103 

Morphine-Scopolamine Anesthesia . . . 104 
Morphine-Scopolamine Preliminary 

to Inhalation Anesthesia . . 105 
Morphine-Scopolamine Preliminary 
to Local and Spinal Anal- 
gesia 105 

Morphine-Scopolamine in Obstetrics. 106 

Scorbutus 108 

Symptoms 108 

Diagnosis 109 

Etiology 109 

Pathology 109 

Prognosis 109 

Treatment 109 

Scorbutus, Infantile. See Infantile 

Scorbutus. 
Scrofula. See various forms of Tuber- 
culosis. 



CONTENTS. 



Vll 



PAGE 

Scrofuloderma. See Tuberculosis of 
the Skin. 

Seasickness 1 10 

Definition and Synonyms 110 

Symptomatology 110 

Complications and Sequelae Ill 

Etiology Ill 

Prognosis 113 

Prophylaxis 113 

Treatment 1 14 

Senega 115 

Preparations and Doses 115 

Physiological Action 115 

Therapeutic Uses 116 

Sepsis, Septic Fever, Septic Infection, 
Septic Poisoning, Septi- 
cemia. See Wounds, Septic. 
Septum, Diseases of. See Nose and 
Nasopharynx, Diseases of. 
Sera. See Diseases in which these are 
used ; also Hematology. 

Serpentaria 116 

Preparations and Doses 117 

Physiological Action 117 

Therapeutic Uses 117 

Shingles. See Herpes Zoster. 

Shock 117 

Definition 117 

Symptoms 117 

Delayed Shock 118 

Shell Shock 118 

Etiology and Pathology 119 

Kinetic Theory 121 

Prophylaxis 122 

Anoci-Association 122 

Treatment 124 

Electrical Shock 127 

Treatment 127 

Silver 128 

Preparations and Doses 128 

Incompatibilities 130 

Modes of Administration 130 

Physiological Action 130 

Poisoning " 132 

Acute Poisoning 132 

Treatment of Acute Poisoning .... 133 

Chronic Poisoning 133 

Treatment of Chronic Poisoning . . 134 

Therapeutics 134 

Gastrointestinal Disorders 134 

Nervous Disorders 136 

Surgical Disorders 136 

Disorders of the Respiratory Tract 137 

Ophthalmic Disorders 138 

Cutaneous Disorders 139 

Venereal Disorders 139 

Removal of Silver Stains 140 

'Sinuses, Nasal Accessory; Diseases of. 141 
Maxillary Sinus or Antrum of High- 
more 141 

Inflammatory Disorders 141 

Acute Inflammation 141 

Chronic Infiammation or Em- 
pyema 142 

Treatment 143 

Tumors of the Maxillary Sinus, or 

Antrum 147 



PAGE 

Sinuses, Nasal Accessory, Diseases of. 
Tumors of the Maxillary Sinus, or 
Antrum (continued). 

Polypi 147 

Cysts 147 

Osteoma 147 

Malignant Tumors 148 

Trea anent , 148 

Frontal Sinus 148 

Inflannnatory Disorders 148 

Acute Inflammation 148 

Chronic Inflammation 149 

Treatment 149 

Tumors of the Frontal Sinus 152 

Mucocele 152 

Cysts 153 

Osteoma 153 

Malignant Tumors 154 

Treatment 154 

Ethmoid Cells 154 

Inflammatory Disorders 154 

Acute Inflammation ; Acute Eth- 

moiditis 154 

Chronic Inflammation or Chronic 

Ethmoiditis 155 

Treatment 156 

Tumors of the Ethmoidal Cells 158 

Benign Tumors 158 

Malignant Tumors 158 

Treatment 158 

Sphenoidal Sinus 159 

Inflammatory Disorders 159 

Acute Inflammation 159 

Chronic Inflammation or Em- 
pyema of the Sphenoidal 

Sinus 159 

Treatment 160 

Tumors of the Sphenoidal Sinus 161 

Benign Tumors 161 

Malignant Tumors 161 

Treatment 161 

Skin-Grafting 161 

Reverdin's Method 161 

Thiersch's Method 162 

Wolfe-Krause Method 163 

Skin-periosteum Bone Grafts 163 

Caterpillar Grafting 163 

Tunnel Grafting 163 

Subcutaneous Skin-Grafting 163 

Anomalies in Grafting 163 

Grafting from Dead Bodies 164 

Sponge-Grafting 164 

Grafting from Animals 164 

Histology and Pathology 164 

Comparison of Methods 164 

Skin, Surgical Diseases of 165 

Sebaceous Cysts, or Wens 165 

Treatment 165 

Furuncle 165 

Diagnosis 165 

Etiology 165 

Treatment 165 

Carbuncle 165 

Doliiiition 165 

Symptoms 166 

Diagnosis 166 

Etiology 166 



Vlll 



CONTENTS. 



PAGE 

Skin, Surgical Diseases of, Carbuncle 
(continued). 

Prognosis 166 

Treatment 166 

Keratosis Senilis 167 

Prognosis 167 

Treatment 167 

Calvus ( Corn ) 167 

Treatment 167 

VerrucTe 168 

treatment lf'8 

Hypertrophicd Scars 168 

Treatment 168 

Keloid 168 

Symptoms 168 

Diagnosis , 169 

Etiology and Pathology 169 

Prognosis 169 

Treatment 169 

Malignant Degeneration of Scars . . 169 

Burns 169 

Definition 169 

Varieties 169 

Symptoms 170 

'Local Effects 170 

Electric and X-ray Burns 171 

Burns of Mucous Surfaces 171 

Constitutional Effects 1/1 

Complications 172 

Diagnosis 172 

Medicolegal Aspects of Burns 172 

Prognosis 173 

Treatment 173 

Constitutional 173 

Local 174 

Treatment of Electrical Burns . . . . 175 

Scar Tissue Deformities 176 

Sodium 176 

Preparations and Doses 176 

Physiological Action 180 

Poisoning by Sodium and Its Salts . . 183 

Sodium Hydroxide 183 

Treatment of Poisoning by Sod- 
ium Hydroxide 183 

Sodium Bicarbonate and Carbonate . 184 

Sodium Chloride 184 

Sodium Nitrate 184 

Sodium Sulphate 185 

Sodium Sulphite and Thiosulphate . 185 

Therapeutics 185 

Gastrointestinal Disorders 185 

Cutaneous Disorders 189 

Genitourinary Disorders 190 

Laryngological and Respiratory Dis- 
orders 190 

Gynecological and Puerperal Dis- 
orders 191 

Constitutional Disorders 192 

Surgical Disorders 193 

Chlorides in Urine 194 

Saline Solution 194 

Preparation 194 

Physiological Action and Uses 194 

Modes of Administration 195 

(1 ) Saline Enteroclysis 195 

(2) Saline Hypodermoclysis 197 

(3) Intravenous Saline Infusion . 198 



PAGE 

Sodium, Saline Solution, Modes of Ad- 
ministration (continued). 

(4) Intraperitoneal Saline Infu- 
sion 199 

Contraindications 199 

Other Solutions 199 

Dawson's Solution 200 

Locke's Solution 2(1) 

Ringer-Locke Solution 200 

Fleig's Solution 200 

H. M. Adier's Solution 200 

Fischer's Solution 200 

Spigelia 200 

Preparations and Doses 201 

Physiological Action 20' 

Poisoning by Spigelia 201 

Therapeutic Uses 201 

Spinal Anesthesia 201 

Physiological Action 202 

Technique 203 

Solutions Used 203 

Site of Injection 204 

Syringe and Needle 205 

Preliminary Narcotization 206 

Associated Local Anesthesia 206 

Induction and Management of Spinal 

Anesthesia 206 

After-treatment 208 

Indications and Advantages of Spinal 

Anesthesia 209 

Contraindications 211 

Technical Difficulties, Complications, 

and Sequelae 212 

Position af the Patient 212 

Breaking of the Needle 212 

Lack of Anesthesia 212 

Dosage 212 

Circulatory Depression 212 

Respiratory Depression 213 

Early After-effects 213 

Nausea and Vomiting 213 

Headache 213 

Backache 213 

Postoperative Pain 213 

Albuminuria 214 

Remote After-effects 214 

Injury to Nervous Tissue 214 

Neurotic Symptoms 214 

Mortality . . .'. 214 

Sacral Anesthesia 216 

Spinal Cord, Diseases of 217 

General Considerations 217 

Infantile Paralysis; Polioencephalo- 

myelitis 217 

Synonyms 217 

Definition 217 

Symptoms 218 

Poliomyelitic Form 220 

Landry's Form 221 

Bulbar Form 221 

Encephalitic Form 221 

Ataxic Form 221 

Polyneuritic Form 221 

Meningitic Form 221 

Abortive Form 222 

Diagnosis 222 

Etiology 224 



CONTENTS. 



IX 



PAGE 

Spinal Cord, Diseases of, Infantile Pa- 
ralysis, Polioencephalomyelitis (con- 
tinued). 

Pathology 225 

Prognosis 225 

Prophylaxis 226 

Treatment 227 

Operative Treatment 229 

Tenotomy and Myotomy 230 

Tendon Shortening 230 

Tendon Lengthening 230 

Tenodesis 230 

Extra-articular Silk Ligaments . 230 
Intra-articular Silk Ligaments . . 230 

Arthrodesis 230 

Articular Transposition 231 

Astragalectomy 231 

Nerve Anastomosis 231 

Tendon Transplantation on Ten- 
don 231 

Tendon Transplantation to Peri- 
osteum 231 

Elongation of Short Tendons 

by Means of Silk Sutures . . 231 

Myelitis 231 

Synonyms 231 

Definition 231 

Symptoms 232 

Diagnosis -^^ 

Etiology 234 

Pathology 235 

Prognosis 236 

Treatment 236 

Amyotrophic Lateral Sclerosis 237 

Definition 237 

Symptoms 237 

Diagnosis 238 

Etiology 238 

Pathology 238 

Prognosis 239 

Treatment 239 

Primary Lateral Sclerosis 239 

Synonyms 239 

Definition 239 

Symptoms 239 

Diagnosis 240 

Etiology 240 

Pathology 240 

Prognosis 240 

Treatment 241 

Landry's Paralysis 242 

Synonyms 242 

Definition 242 

Symptoms 242 

Diagnosis 243 

Etiology 243 

Pathology 244 

Prognosis 244 

Treatment ■ ■ 244 

Hereditary Ataxia 245 

Synonyms 245 

Definition 245 

Symptoms 245 

Diagnosis 246 

Etiology 246 

Pathology 247 

Prognosis 247 



PAGE 

Spinal Cord, Diseases of, Hereditary 
Ataxia (continued). 

Treatment 247 

Ataxic Paraplegia 248 

Synonyms 248 

Definition 248 

Symptoms 248 

Diagnosis 248 

Etiology 248 

Pathology 249 

Prognosis 249 

Treatment 249 

Syringomyelia 249 

Definition 249 

Symptoms 249 

Diagnosis 251 

Etiology 252 

Pathology 252 

Prognosis 253 

Treatment 253 

Spinal Cord and Nerves, Injuries and 

Surgery of 254 

Nerves, Injuries of 254 

Subcutaneous Nerve Injuries 254 

Concussion 254 

Contusion 254 

Pressure Paralysis 254 

Stretching and Laceration 254 

Displacement 255 

Treatment 255 

Open Nerve Injuries 256 

Effects of Nerve Division 256 

Process of Repair 256 

Symptoms 257 

Treatment 258 

Nerve Suture or Neurorrhaphy 258 

Neuroplasty 259 

Nerve-grafting, Anastomosis, or 

Implantation 260 

Tubulization 260 

Peripheral Nerve Injuries 261 

Nerve Stretching or Neurectasy . . 263 
Nerve Extraction or Avulsion .... 264 

Neurectomy 264 

Neurotomy 264 

Removal of the Gasserian Gang- 
lion or Its Sensory Roqt .... 265 
Removal of the Cervical Sympa- 
thetic 266 

Spinal Meningitis. See Meningitis. 
Spinal Paralvsis. Infantile. See Spinal 

Cord: Infantile Paralysis 
Spinal Paralysis, Spastic. See Spinal 
Cord : Primary Lateral Scle- 
rosis. 

Spine, Diseases and Injuries of 266 

Tuberculosis of the Spine (Pott's 

Disease; Spondylitis) 266 

Symptoms and Diagnosis 266 

Etiology 269 

Treatment 2()9 

Plaster-of-Paris Jacket 271 

Management of Abscess 273 

b'orcilde i\eduction of Deformity . 274 

Hibbs's Operation 274 

Albee's Bone Grafts 275 



X 



CONTENTS. 



PAGE 

Spine, Diseases and Injuries of (con- 
tinued). 

Scoliosis, or Rotary Lateral Curva- 
tures 275 

Etiology 276 

Diagnosis 276 

Pathology 278 

Treatment 279 

Abbott's Method 280 

Spondylitis Deformans ; Bechterew's 

Disease 286 

Symptoms 286 

Treatment 286 

Spinal Localization 286 

Tumors of the Spinal Cord 287 

Symptoms 287 

Diagnosis 287 

Treatment 287 

Sacrococcygeal and Sacroanal Tumors. 287 
Congenital Deformities of the Spine . . 290 

Myelocele or Rachischisis 290 

Spina Bifida 290 

Prognosis 291 

Treatment 291 

Technique of Excision of the 

Sac 291 

Wounds and Injuries of the Spine . . 293 
Gunshot and Punctured Wounds . . . 293 

Meningomyelorrhaphy 294 

Sprain and Dislocation 294 

Symptoms 294 

Dislocation of a Vertebra 295 

Treatment 295 

Bed-sores 295 

Treatment 296 

Sacroiliac Disease 296 

Treatment 296 

Disorders of the Coccyx 297 

Coccygodynia 297 

Laminectomy 297 

Spine, Dislocation of. See Dislocations. 
Spirillosis. See Relapsing Fever. 
Spirit of Mindererus. See Ammonium. 
Splanchnoptosis. See Intestines : Vis- 
ceroptosis. 

Spleen, Diseases of 298 

Functions of the Spleen 298 

Anomalies 299 

Movable or Wandering Spleen 300 

Symptoms 300 

Diagnosis 301 

Treatment 301 

Acute Hyperemia or Congestive En- 

larsrement of the Spleen .... 301 

Symptoms 302 

Treatment 302 

Abscess of the Spleen or Acute Sup- 
purative Splenitis 302 

Symptoms 302 

Treatment 303 

Rupture of the Spleen 303 

Symotoms 303 

Treatment 304 

Splenomegalv, or Chronic Enlarged 

Spleen 304 

Syphilitic Splenomegaly 304 

Tuberculous Splenomegaly ■ 305 



PAGE 

Spleen, Diseases of, Splenomegaly, or 
Chronic Enlarged Spleen (continued). 
Malarial Splenomegaly (Ague 

Cake) 305 

Thrombotic Splenomegaly 305 

Amyloid Spleen 306 

Miscellaneous Forms of Spleno- 
megaly 306 

Treatment 308 

Splenic Anemia 308 

Symptoms 309 

Diagnosis 310 

Treatment 311 

Gaucher's Splenomegaly 312 

Symptoms 312 

Treatment 313 

Splenomegalic Polycythemia, or Ery- 
thremia 313 

Symptoms 313 

Etiology and Pathology 314 

Treatment 314 

Perisplenitis : Capsulitis : Capsular 

Splenitis 314 

Symptoms 314 

Treatment 315 

Tumors of the Spleen 315 

Symptoms 315 

Treatment 316 

Spleen, Injuries of. See Abdominal 
Injuries . 

Squill 316 

Preparations and Doses 316 

Phvsiological Action 317 

Poisoning by Squill 317 

Treatment of Poisoning 317 

Therapeutic Uses 317 

Squint. See Strabismus. 
St. Anthony's Dance. See Chorea. 
St. Anthony's Fire. See Erysipelas. 
St. Vitus's Dance. See Chorea. 
Staphylorrhaphy. See Surgical Ana- 
plasty, or Plastic Surgery : 
Cleft Palate. 
Status Lymphaticus. See Thymus, Lym- 
phaticus, and Mediastinum. 
Diseases of. 

Sterilization and Disinfection 318 

Thermal Sterilization 318 

Mechanical Sterilization 320 

Chemical Sterilization 320 

Practical Uses of Chemical Disin- 
fectants 320 

Disinfection of Surgeon's Hands. 320 
Disinfection of the Operative 

Field 321 

Sterilization of Surgical Para- 
phernalia 321 

Disinfection of Bed and Body 

Clothing 321 

Disinfection of Bath Water 322 

Disinfection of Feces, Urine, and 

Sputum 322 

Disinfection of the Sickroom 322 

Disinfection of Passenger Cars . . . 323 

Disinfection of Books 323 

Stillingia 323 

Preparations and Doses . . = 323 



CONTENTS. 



XI 



PAGE 

Stillingia (continued). 

Physiological Action 323 

Therapeutic Uses 324 

Stokes-Adams Disease. See Heart and 
Pericardium : Heart-block. 

Stomach Cancer of 324 

Etiology 324 

Symptomatology and Diagnosis 324 

Laboratory Diagnosis 326 

X-ray Examination 328 

Treatment 329 

Stomach, Diseases of 330 

Gastric Neuroses 330 

Synonyms 330 

General Considerations 330 

Neurotic Secretory Conditions 330 

Hyperacidity 330 

Etiology 330 

Symptoms 330 

Diagnosis 331 

Prognosis 331 

Treatment 331 

Subacidity and .\nacidity 333 

Etiology 333 

Symptoms 333 

Diagnosis 333 

Prognosis 333 

Treatment 333 

Heterochylia 335 

Treatment 335 

Gastromyxorrhea 335 

Etiology 335 

Symptoms 335 

Diagnosis 335 

Treatment 335 

Neurotic Sensory Disturbances 336 

Hyperesthesia Gastrica 336 

Etiology 336 

Symptoms 336 

Diagnosis 336 

Treatment 336 

Gastralgia Nervosa 337 

Etiology 337 

Symptoms 337 

Diagnosis 337 

Treatment 337 

Neurasthenia Gastrica 338 

Polysymptomatic Neurosis or Nerv- 
ous Dyspepsia 338 

Etiology 338 

Symptoms 338 

Diagnosis 339 

Prognosis 339 

Treatment 339 

Bulimia 340 

Parorexia 34;) 

Polyphagia 340 

Akoria 341 

Gastralgokcnosis 341 

Anorexia Nervosa 341 

Sitophobia 341 

Disturbances of Gastric Motility 341 

Myasthenia Gastrica and Gastric 

Atony 341 

Etiology 341 

Symptoms and Diagnosis 342 

Prognosis 343 



PAGE 
Stomach, Diseases of, Disturbances of 
Gastric Motility, Myasthenia Gastrica 
and Gastric Atony {continued). 

Treatment 343 

Secondary Gastric Dilatation 344 

Etiology ■ 344 

Symptoms 345 

Diagnosis 345 

Prognosis 346 

Treatment 346 

Acute Postoperative Dilatation of 
the Stomach and Duo- 
denum 346 

Etiology 346 

Symptoms and Diagnosis 346 

Prognosis 347 

Treatment 348 

Gastropolyasthenia 349 

Symptoms and Etiology 349 

Diagnosis 350 

Prognosis 350 

Treatment 350 

Cardiospasm 350 

Etiology 350 

Symptoms 351 

Diagnosis 351 

Prognosis 351 

Treatment 351 

Gastrospasm ( Pseudo Hour-glass 

Contraction) 352 

Diagnosis 352 

Treatment 352 

Pylorospasm 352 

Etiology 352 

Symptoms 352 

Diagnosis 352 

Treatment 352 

Nervous Hypermotility 353 

Etiology 353 

Symptoms 353 

Diagnosis 353 

Prognosis 353 

Treatment 353 

Regurgitations 354 

Symptoms 354 

Prognosis 354 

Treatment 354 

Merycism 354 

Symptoms 354 

Treatment 354 

Eructatio Nervosa (Aerophagia) .. 355 

Symptoms 355 

Diagnosis 355 

Treatment 355 

Singultus Gastrica Nervosa (Hic- 
cough ) 355 

Vomitus Nervosus 355 

Varieties 355 

Symptoms 356 

liiagnosis 356 

Treatment 356 

Pneumatosis 357 

Symptoms and Diagnosis 357 

Treatment 357 

Peristaltic Unrest 357 

Symptoms 357 

Diagnosis 357 



Xll 



CONTENTS. 



PAGE 

Stomach, Diseases of. Disturbances of 
Gastric Motility, Peristaltic Unrest 
(continued). 

Treatment 357 

Antiperistaltic Unrest, 358 

Pyloric incontinence 358 

Symptoms and Diagnosis 358 

Treatment 358 

Duodenal Regurgitation Due to I'"atty 

Foods 358 

Symptoms 358 

Diagnosis 3^8 

Treatment 359 

Acute Gastritis 359 

Acute Catarrhal Gastritis (Simple 
Gastritis, Acute Indiges- 
tion) 359 

Etiology 359 

Pathology 359 

Symptoms 360 

Diagnosis 360 

Treatment 361 

Acute Suppurative Gastritis (Phleg- 
monous Gastritis, Gastric 

Abscess ) 362 

Etiology 362 

Pathology 362 

Symptoms 362 

Diagnosis 363 

Treatment 363 

Infectious Gastritis 363 

Toxic Gastritis 363 

Etiology 363 

Pathology 363 

Symptoms 363 

Diagnosis 364 

Treatment 364 

Antidotes 364 

Chronic Gastritis 364 

Varieties 364 

Etiology 365 

Pathology 365 

Symptoms 366 

Complications 367 

Diagnosis 367 

Gastric Neuroses 367 

Gastric Ulcer 368 

Gastric Cancer 368 

Amyloid Degeneration of the 

Stomach 368 

Prognosis 368 

Treatment 368 

Surgical 373 

Gastric and Duodenal Ulcer 373 

Etiology 373 

Pathology 373 

Symptoms 374 

Special Features of Duodenal 

Ulcer 3/6 

Diagnosis 377 

Differential Diagnosis 378 

Gastralgia 378 

Carcinoma 378 

Hyperchlorhydria and Gastrosuc- 

corrhea 37S 

Hemorrhagic and Other Forms of 

Gastritis 379 



PAGE 

Stomach, Diseases of. Gastric and Duod- 
enal Ulcer, Differential Diagnosis (con- 
tinued). 

Pylorospasm 379 

Appendicitis 379 

Hyperemesis of Pregnancy 380 

Uremia 380 

Biliary Conditions 380 

Renal' Colic 380 

Arteriosclerosis 381 

Spinal and Other Diseases 381 

Post-ulcer Conditions 381 

Prognosis 381 

Prophylaxis 382 

Treatment 382 

Diet 382 

Medicinal Treatment 385 

Special Treatment of Symptoms . 387 

Sippy's Treatment 388 

Surgical Treatment 388 

Syphilis of the Stomach 391 

Pathology 391 

Symptoms and Diagnosis 391 

Treatment 392 

Tuberculosis of the Stomach 392 

Etiology 392 

Pathology 392 

S3-mptoms and Diagnosis 393 

Treatment 393 

Pseudomembranous Gastritis 394 

Benign Tumors of the Stomach 394 

Pathology 394 

Adenomata 394 

Papillomata 394 

Myomata and Fibromyomata .... 394 

Lipomata 394 

Myxomata 394 

Lymphadenomata 394 

Retention Cysts 395 

Gastroliths and Foreign Bodies . . 395 

Hypertrophy of the Pylorus 395 

Symptoms and Diagnosis 395 

Treatment 396 

Stomach, Injuries and Surgical Diseases 
of. See Abdomen. Surgery 
of, and Abdominal Injuries. 
Stomatitis. See Mouth, Diseases of. 

Stovaine 396 

Physiological Action 397 

Poisoning 397 

Therapeutics 397 

Strabismus 398 

Definition 398 

Symptoms 398 

Varieties 400 

Diagnosis 401 

Prognosis 493 

Treatment ' 403 

After-treatment 406 

Stramonium 406 

Preparations and Doses 406 

Physiological Action 407 

Therapeutic Uses 407 

Strontium 407 

Preparations and Doses 407 

Physiological Action 407 

Therapeutics 408 



CONTENTS. 



Xlll 



'page 
Strontium, Therapeutics (continued). 
Acute Rheumatism and Constitu- 
tional Disorders 408 

Nephritis 408 

Cardiovascular Disorders 409 

Gastrointestinal Disorders 409 

Nervous Disorders 409 

Cutaneous Disorders 409 

Strophanthus 409 

Preparations and Doses 409 

Physiological Action 410 

Untoward Effects and Poisoning 411 

Therapeutics 411 

Struma. See Goiter. 
Strychnine. See Nux Vomica. 
Stye. See Eyelids, Diseases of : Hor- 
deolum. 
Stypticin. See Cotarnine. 
Styptol. See Cotarnine. 
Subphrenic Abscess. See Liver, Dis- 
eases of. 
Suggestion-therapy ; Psychotherapy ; 

Hypnotherapy (Hypnotism). 414 

Psychotherapy 414 

Psychotherapeutic Technique 415 

Hypnotherapy ("Hypnotism") 418 

Technique 419 

Therapeusis 420 

Sulphonal 421 

Modes of Administration 421 

Physiological Action 422 

Contraindications 422 

Untoward Effects and Poisoning .... 422 

Acute Sulphonal Poisoning 423 

Treatment of Acute Sulphonal Pois- 
oning 423 

Chronic Sulphonal Poisoning 424 

Treatment of Chronic Sulphonal 

Poisoning 425 

Therapeutics 425 

Sulphur 426 

Preparations and Doses 427 

Physiological Action 427 

Untoward Effects and Poisoning 428 

Treatment 42<S 

Therapeutics 428 

Gastrointestinal and Constitutional 

Disorders 428 

Respiratory Disorders 429 

Chlorosis 430 

Cutaneous Disorders 430 

As Insecticide 431 

Sulphuric Acid 431 

Preparations and Doses 431 

Physiological Action 431 

Treatment of Poisoning 431 

Tlierapeutic Uses 432 

Sulphurous Acid 432 

Action and Uses 432 

Sumbul 433 

Preparations and Doses 433 

Physiological Action 433 

Therapeutic Uses 433 

Sunstroke. See Heat Exhaustion. 
Suprarenal Capsules. Duscases of. See 
Adrenals, Diseases of. 



PAGE 

Suprarenal Organotherapy. See Animal 

Extracts. 

Surgical Anaplasty, or Plastic Surgery.. 433 

General Considerations 433 

General Technique 434 

Deformities of the Lips 434 

Varieties 434 

Median Harelip 434 

Simple Unilateral Harelio 434 

Unilateral Harelip with Fissure 

of the Bony Parts 434 

Simple Bilateral Harelip 434 

Complicated Bilateral Harelip .... 434 

Treatment 435 

After-treatment and Complica- 
tions 435 

Hypertrophy of the Lips 437 

Deformities Due to Injury 437 

Treatment 437 

Everted Lip 437 

Inverted Lip 438 

Excision of Labial Cancers 438 

Formation of the Lower Lip after 

Complete Excision 438 

Restoration of the Upper Lip 439 

Macrostoma (Large Mouth ) 439 

Treatment 439 

Microstoma (Congenital Atresia Oris). 439 

Treatment 439 

Cleft Palate 439 

Treatment 439 

Staphylorrhaphy 440 

Uranoplasty 440 

After-treatment 441 

Rhinoplasty 442 

Indian Method 442 

Italian Method 442 

Reduction of Hump-nose (Aquiline 

Nose) 443 

Stenosis of the Nose 443 

Paraffin Injections (Hydrocarbon Pro- 
thesis) 443 

Plastic Surgery of the Ear (Oto- 
plasty) 443 

Outstanding Ears 443 

Abnormally Enlarged Ear (Macro- 

tia) 444 

Repair of Clefts and Fissure of the 

Lobule 444 

Enlarged Lobule 444 

Elongated Lobule 444 

Shortened Lobule 444 

Adherent and Undeveloped L(jl)u!c . 444 

.Sweat-glands, Diseases of the 444 

Anhidrosis 444 

Treatment 444 

Hyperidrosis, or Excessive Sweatin.u . 445 

Treatment 445 

Bromidrosis 446 

Treatment 446 

Chromidrosis, or Colored Sweat 447 

Treatment 448 

Tumors of the Sweat-glands 448 

Treatment ' 448 

Svcosis. See Hair, Diseases of. 
Syni])le])haron. .See Eyelids. 
Synovitis. Sec Joints. 



XIV 



CONTENTS. 



PAGE 

Syphilis 44H 

Etiology and Symptoms 448 

Incubation Period of Syphilis 449 

Specific Micro-organism of Syphilis. 449 

Primary Local Changes 450 

The Initial Lesion, or Chancre 452 

Varieties of Induration 453 

Diagnosis of Chancre 454 

Loss of Tissue in Chancre 454 

Secretion of Chancre 455 

Comparative Frequency of Chancre 

and Chancroid 455 

Complications of Chancre 455 

Mixed Chancre 456 

Phagedenic Chancre 456 

Infectious Secretions in Syphilis 

and Infection 456 

Modes of Contagion 457 

Duration of Chancre 45(S 

Number of Chancres 458 

General Infection, Constitutional, or 

Secondary Syphilis 458 

Diagnosis 458 

Constitutional Syphilis 458 

Wassermann Test 458 

Sources of Fallacy 458 

General Adenopathy 459 

The Roseola 459 

Syphilitic Prodromes 459 

Pharyngofaucial Infiltration 460 

The Papular Syphilide 460 

Syphilitic Alopecia 460 

Syphilis of the Nails 460 

Pustules, Vesicles, and Precocious 

Skin-lesions 460 

Special Mucous Lesions 460 

Visceral involvement 461 

Early Ocular Syphilis 461 

Early Osseous Symptoms 461 

Earlv Nerve Involvement in Syph- 
ilis 461 

Late Syphilis, Sequelar or So-called 

Tertiary Syphilis 462 

The Tubercular Syphilide (Gummy 

Infiltration) 462 

The Gumma 463 

Late, or Sequelar, Nerve and 

Brain Syphilis 463 

Syphilides 464 

Prognosis 465 

Curability of Syphilis 466 

When May a Syphilitic Marry? 466 

Congenital Syphilis 466 

Acquired Syphilis in Children 466 

Syphilis Hereditaria Tarda 467 

Lesions of Congenital Syphilis . . . 467 

Treatment 468 

New Remedies 471 

Salvarsan 471 

Method 473 

Technique 473 

Local Treatment of Chancre 473 

Syringomyelia. See Spinal Cord, Dis- 
eases of. 

Tabes Dorsal is 474 

Definition 474 



PAGE 

Talies Dorsalis (continued). 

Varieties 474 

Symptoms 475 

Symptomatic Analysis 477 

The Reflexes 477 

Pupillary Symptoms 478 

Optic Atrophy 479 

Ocular-muscle Palsies 479 

Ataxia 479 

Tabetic Crises 480 

Cardiac Crises 481 

Sensory Symptoms 481 

Trophic Symptoms 481 

Vesical, Rectal, and Sexual 

Symptoms 482 

Special Senses 483 

Diagnosis 483 

Etiology 484 

Pathology 486 

Complications 488 

Prognosis 488 

Treatment 489 

Tachycardia. See Heart : Frequent 

Pulse. 
Talipes. See Orthopedic Surgery. 

Tamarind 496 

Action and Uses 496 

Tannic Acid 496 

Preparations and Doses 497 

Physiological Action 497 

Therapeutic Uses 498 

Tansy 499 

Preparations and Doses 499 

Physiological Action 499 

Poisoning by Tansy 499 

Treatment of Poisoning 499 

Therapeutic LTses 499 

Tape-worm. See Parasites, Disease Due 
to. 

Tar 499 

Preparations and Doses 500 

Physiological Action 500 

Poisoning by Tar 500 

Treatment 501 

Therapeutics 501 

AfYcctions of Mucous Membranes. 501 

External Uses 501 

Lysol 502 

Poisoning by Lysol 502 

Therapeutics 502 

Pixol 503 

Taraxacum 503 

Preparations and Doses 503 

Physiological Action 503 

Therapeutic Uses 503 

Tartar Emetic. See Antimony. 
Telangiectasis. See Blood-vessels, Tum- 
ors of. 
Tendons, Bursse, and Fasciae, Diseases 

of 504 

Diseases of the Tendons 504 

Acute Tenosynovitis 504 

Symptoms 504 

Palmar Abscess 504 

Felon, or Whitlow 504 

Treatment 504 



CONTENTS. 



XV 



PAGE 

Tendons, Bursae, and Fasciae, Diseases of, 
Diseases of the Tendons (continued). 
Chronic Tenosynovitis, or Thecitis.. 50^) 

Treatment 505 

Injuries of tendons. Displacement or 

Dislocation 506 

Treatment 507 

Rupture 507 

Treatment 507 

Wounds of Tendons 507 

Treatment 508 

Diseases of the Bursse 503 

Acute Bursitis 508 

Treatment 508 

Chronic Bursitis 508 

Housemaid's Knee 509 

Treatment 509 

Bunion 509 

Treatment 509 

Ganglion 510 

Treatment 510 

Contraction of Tendons and Fascia . . 510 

Dupuytren's Contracture 510 

Treatment 510 

Trigger-finger 511 

Treatment 511 

Tendon Transplantation 511 

Tetanus 512 

■ Synonyms • • 512 

Definition 512 

Symptoms 512 

Diagnosis 514 

Etiology 515 

Bacteriology 517 

Pathology 518 

Prognosis 518 

Treatment 519 

Prophylaxis 525 

Theobromine. See Diuretin. 

Theocine 527 

Physiological Action 527 

Therapeutic Uses 527 

Thermic Fever. See Heat Exhaustion 
and Thermic Fever. 

Thiocol 5?7 

Preparations and Doses 528 

Physiological Action 528 

Therapeutic Uses 528 

Thiosinamine 528 

Physiological Action 528 

Untoward Effects and Poisoning 529 

Therapeutics 529 

Thomsen's Disease. See Muscles : Myo- 
tonia Congenita. 
Thoracentesis. See Chest, Injuries and 

Surgical Disorders of. 
Thoracic Duct, Injuries of. See Chest, 
Injuries and Surgical Dis- 
orders of. 
Thoracoplasty. See Chest, Injuries and 

Surgical Disorders of. 
Thoractomy. See Chest, Injuries and 

Surgical Disorders of. 
Thorax, Wounds and Injuries of. See 
Chest, Injuries and Surgical 
Disorders of. 
Thorium. See X-rays and Padii'.ri. 



PAGE 

Thread-worms. See Parasites : Oxyuris 

Vermicularis. 
Thrombosis. See Vascular System, Sur- 
gical Diseases of. 
Thrush. See Mouth, Lips, and Jaws : 
Parasitic Stomatitis. 

Thymol 531 

Physiological Action 531 

Untoward Effects and Poisoning .... 532 
Treatment of Thymol Poisoning . . . 532 

Therapeutics 532 

Internal and Systemic Uses 532 

Local Uses 533 

Thymus, Lymphatics, and Mediastinum, 

Diseases of 533 

Functions of the Thymus 533 

Functions of the Lymphatics 533 

Anomalies of the Thymus and Lym- 
phatics 534 

Diseases of the Thymus 534 

Enlargement of the Thymus and 

Lymphatics 535 

Status Thymicolymphaticus 535 

Symptoms 535 

Thymic Stridor 535 

Thymic xA.sthma 535 

Thymic Death 535 

Thymic Symptoms 536 

Lymphatic Symptoms 537 

Pathogenesis 538 

Treatment 538 

Thymectomy Technique 539 

Prevention of Paroxysms 540 

Diseases of the Lymphatics 540 

Lymphadenitis 540 

Lymphangitis 541 

Symptoms 541 

Diagnosis 541 

Etiology 542 

Treatment 542 

Lymphangiectasia ; Lymphangioma . 542 

Symptoms 543 

Etiology 543 

Treatment 544 

Tumors of the Lympliatic System . . 544 

Treatment 544 

Glandular Fever 545 

Symptoms 545 

Etiology 545 

Treatment 546 

Mediastinum, Diseases of the 546 

Acute and Chronic Mediastinitis .... 546 

Symptoms 547 

Acute Mediastinitis 547 

Chronic Mediastinitis 547 

Abscess of the Mediastinum .... 547 
Tuberculous Mediastinal Lym- 
phadenitis 548 

Tuberculosis of the Bronchial 

Glands 548 

Diagnosis 549 

Treatment 550 

Tumors of the Mediastinum 551 

Treatment 552 

Th\roi(I Gland, Diseases of 552 

Functions 552 

Hypothyroidia 552 



XVI 



CONTENTS. 



PAGE 

Thyroid Gland, Diseases of, Hypothy- 
roidia {continued) . 

Symptoms 552 

Diagnosis 554 

Etiology 554 

Pathogenesis 555 

Treatment 555 

Myxedema, or Progressive Hypothy- 

roidia ' 555 

Definition 556 

Symptoms 556 

Diagnosis 558 

Etiology 558 

Treatment 558 

Surgical Disorders of the Thyroid Ap- 
paratus 559 

Injuries 559 

Treatment 560 

Surger>' of the Thyroid 560 

Indications 560 

Operative Precautions 561 

Operative Technique 562 

Thyroid Therapy. See Animal Extracts : 

Thyroid Gland. 
Thyroidism. See Animal Extracts : 

Thyroid Gland. 
Thyroiditis. See Goiter. 
Thyrotomy. See Larynx, Diseases and 

Surgery of. 
Tic Douloureux. See Nerves, Peripheral, 

Diseases of. 
Tinea. See Parasites, Diseases Due to. 
Tinea Favosa, Tonsurans, Trichophy- 
tina. .See Hair, Diseases of. 
Tinea Nodosa. See Piedra. 
Tinnitus Aurium. See Internal Ear. Dis- 
orders of. 

Tobacco 563 

Physiological Action 563 

Acute Poisoning 563 

Chronic Poisoning 563 

Treatment of Acute Poisonine 564 

Toe, Hammer-. See Orthopedic Surgery. 
Toe-nails, Ingrowine. See Nails, Dis- 
eases and Injury of. 

Tongue, Diseases of 564 

Tongue-tie, or Ankyloglossia 564 

Treatment 564 

Lingual Paoillitis 564 

Treatment 565 

Parenchymatous Glossitis 565 

Symptoms 565 

Treatment 565 

Chronic Glossitis 565 

Svmptoms 565 

Treatment 565 

Leucoplakia 566 

Treatment 566 

Eczema of the Tongue 566 

Treatment 566 

Ulceration of the Tongue 566 

Simple Ulcer 566 

Syphilitic Ulcer 566 

Tuberculous Ulcer 567 

Cancerous Ulcer 567 

Treatment 567 

Tumors of the Tongue 567 



PAGE 

Tongue, Diseases of. Tumors of the 
Tongue {continued) . 

Treatment 567 

Cancer of the Tongue 567 

Symptoms 567 

Etiology ■ . 568 

Prognosis 568 

Treatment 568 

Butlin's Technique 568 

Whitehead's Technique 569 

Kocher's Technique 569 

After-treatment 569 

Injuries of the Tongue 570 

Treatment 570 

Tongue-tie. See Tongue, Diseases of. 
Tonsils. See Pharynx and Tonsils, Dis- 
eases of. 
Torticollis. See Muscles, Diseases of. 
Toxemia. See Wounds, Septic. 
Toxic Foods, or Ptomaine Poisoning .... 570 

Meat Poisoning 570 

Bacillus Enteritidis 570 

Bacillus Botulinus 571 

Bacillus Proteus 571 

Bacteria of Diseased Meat . . 571 

Symptoms 571 

Fish Poisoning 572 

Symptoms 572 

Shellfish Poisoning 572 

Symptoms 573 

Milk. Cream and Cheese Poisoning . 573 

Symptoms 573 

Mushroom Poisoning 573 

Symptoms 574 

Treatment of Food Poisoning 574 

Grain and Vegetable Poisoning .... 575 

Ergot 575 

Chicken-pea 575 

Sprouting Potatoes 575 

Treatment 575 

Pellagra, or Maidism 575 

Pathology 576 

Symptoms 576 

Treatment 576 

Trachoma. See Conjunctiva. Diseases 

of. 
Transfusion. See Venesection and 

Transfusion. 
Traumatic Neuroses. See Vascular Sys- 
tem, Disorders of. 
Trematodes. See Parasites, Diseases 
Due to. 

Tremors 577 

Senile Tremor 578 

Hysterical Tremor 578 

Hereditary or Family Tremor 578 

Toxic Tremor 578 

Infantile Tremor 578 

Intention or \'olitional Tremor . . 578 

Etiology and Pathogenesis 579 

Treatment 579 

Paralysis .A.gitans (Parkinson's Dis- 
ease; Shaking Palsy) 580 

Symptoms 580 

Diagnosis 582 

Etiology, Pathogenesis, and Path- 
ology 582 



CONTENTS. 



xvii 



PAGE 

Tremors, Paralysis Agitans (Parkinson's 
Disease; Shaking Palsy) (continued). 

Treatment 583 

Multiple Sclerosis 585 

Synonyms 585 

Definition 585 

Symptoms 585 

Diagnosis 586 

Etiology 586 

Pathology 587 

Prognosis 587 

Treatment 587 

Trichocephalus Dispar. See Parasites, 
Diseases Due to. 

Trichophytosis 588 

Symptoms 588 

Etiology 588 

Prognosis 588 

Treatment 588 

Trigger Finger. See Tendons, Bursse 
and Fascise, Diseases of. 

Trional 589 

Physiological Action 589 

Poisoning by Trional 589 

Treatment 589 

Therapeutic Uses 590 

Tropacocaine 590 

Physiological Action 590 

Untoward Symptoms 590 

Therapeutic Uses 590 

Trypanosomiasis, or Sleeping Sickness. 591 

Symptoms 591 

Diagnosis • • 591 

Prophylaxis 591 

Treatment 592 

Tuberculosis, Acute 592 

Acute Miliary Tuberculosis 593 

Symptoms and Diagnosis 593 

General or Typhoid Form 593 

Pulmonary Form 594 

Meningeal Form 594 

Diagnosis 595 

Pathology 595 

Treatment 595 

Acute Pneumonic Phthisis 596 

Symptoms 596 

Treatment 596 

Tuberculosis, Chronic Pulmonary 597 

Symptomatology 597 

Loss of Strength 597 

Indigestion 597 

Anorexia 598 

Anemia 598 

Autonomic Disturbances 598 

Lowered Blood-pressure 598 

Increased Pulse Frequency 598 

Fever 598 

Cough 598 

Expectoration 598 

Hemoptysis 598 

Hoarseness 599 

Pain 599 

Night-sweats 599 

Emaciation 599 

Dyspnea 599 

Diarrhea 599 

Neuritis 599 



PAGE 

Tuberculosis, Chronic Pulmonary,Symp- 
tomatologv (continued). 

Psychical Changes 599 

Physical Examination 599 

Inspection 599 

Palpation 601 

Percussion 601 

Auscultation 603 

X-ray Examination 606 

The Blood 606 

Sputum : Microscopic Examination 

of 607 

Diagnosis 608 

Differential Diagnosis 609 

Etiology and Pathogenesis 609 

Pathology 611 

Prognosis 612 

Treatment 613 

Fresh Air 613 

Rest 614 

Exercise 614 

Respiratory Exercises 615 

Diet 615 

Clothing ■ • . 616 

Bathing 616 

Chest Compress 617 

Tuberculins and Sera 617 

Iodine 619 

Creosote and its Derivatives 620 

Arsenic and its Compounds 620 

Calcium 620 

Thyroid Gland 620 

Nuclein 620 

Cinnamic Acid 621 

Mercury 621 

Strychnine 621 

Ichthyol 621 

Camphor 621 

Digitalis 621 

Nitroglycerin 621 

Quinine 621 

Urea 622 

Iron 622 

Other Drugs 622 

Surgical Treatment 622 

Artificial Pneumothorax : 622 

Chondrotomy 623 

Extra-plcural Thoracoplasty 623 

Inhalations 623 

Treatment of Symptoms 623 

Fever 623 

Night-sweats 623 

Cough 623 

Hemoptysis 623 

Prophylaxis 623 

Tuberculosis of the Serous Membranes 

and Skin 625 

Mescntric Tuberculosis or Tabes 

Mesenterica 625 

Symptoms 625 

Diagnosis 625 

Prognosis 626 

Treatment 626 

Tuberculosis of the Myocardium 626 

Treatment 626 

Tul)crculosis of the Skin 626 

Scrofuloderma 626 



XVlll 



CONTENTS. 



PAGE 

Tuberculosis of the Serous Membranes 
and Skin, Tuberculosis of the Skin, 
Scrofuloderma {c(»iliiiucd }. 

Symptoms 626 

Etiology and Pathogenesis 626 

Treatment 627 

True Tuberculosis or Tul)erculosis 

Cutis 627 

Treatment 627 

Tuberculosis Verruca Cutis 627 

Symptoms 627 

Treatment 627 

Lupus Vulgaris 627 

Symptoms 628 

Diagnosis 628 

Etiology and Pathology 628 

Prognosis 628 

Treatment 629 

Lupus Erythematosus 630 

Symptoms 630 

Etiology 631 

Treatment 631 

Turpentine (Terebene; Terpin Hy- 
drate ) 632 

Preparations and Doses 632 

Physiological Action 633 

Untoward Effects and Poisoning 633 

Treatment of Poisoning 633 

Therapeutics 633 

Twilight Sleep. See Scopolamine. 
Typhlitis. See Appendicitis. 

Typhoid Fever 635 

Symptoms 635 

Varieties of Typhoid Fever 637 

The Temperature 637 

Chills 638 

The Skin 638 

Bed-sores 639 

The Digestive System 639 

The Stomach 639 

The Intestines 639 

Meteorism 639 

Pain 639 

The Rectum 640 

The Abdominal Organs 640 

The Gall-bladder 640 

The Spleen 640 

The Respiratory System 640 

The Circulatory System 640 

Blood-pressure 640 

The Nervous System 640 

The Genitourinary System 641 

The Reproductive Organs 641 

Complications 641 

Perforation 642 

Diagnosis 644 

The Bordet-Gengou Reaction 645 

The Ophhalmic Reaction in Ty- 
phoid 646 

Isolation of Typhoid Bacilli from 

Body Fluids 646 

Etiology 647 

Pathology 649 

Histology 650 

The Blood in Typhoid Fever 650 

Prognosis 651 

Age 651 



PAGE 

Typhoid Fever, Prognosis (continued) . 

Habits 651 

Severity of Infection 651 

Complications 651 

Per f oration 65 1 

Relapse 651 

Treatment 651 

1. Diet and General Management . . . 652 

2. Hydrotherai)y 654 

3. Medicinal Treatment 655 

4. Vaccine and Serum Treatment . . 656 

5. Treatment of Complications .... 656 
Treatment of Convalescence 657 

The Public Health Aspect of Typhoid 

Fever 657 

Purification of Water 658 

Filtration 658 

Slow Sand Filters 658 

Mechanical Filters 659 

Chlorine Gas 660 

Flies ih Tj'phoid P'ever 660 

Prophyla.xis 661 

Typhoid Vaccination 663 

Paratyphoid Fever 663 

Symptoms 663 

Complications 664 

Diagnosis 664 

Treatment 664 

Typhoid Fever in Infancy 664 

Typhoid Fever in Early Childhood . . 665 
Typhoid Fever in Later Childhood . . 665 

Typhus Fever 665 

Definition 665 

Symptoms 665 

Brill's Disease 666 

Diagnosis 666 

Etiology and Pathologv 667 

Prognosis 667 

Prophylaxis 668 

Treatment 668 

Ulcers and Varicose Ulcers. See Vas- 
cular System, Surgical Dis- 
eases of. 

Uremia 668 

Symptoms 669 

Acute Uremia 669 

Chronic Uremia 669 

Diagnosis 670 

Etiology 671 

Treatment 671 

Urea, Determination of 672 

Specific Gravity Method 672 

Sodium Hypobromite Method 672 

Davy's Method 673 

Benedict's Method 673 

Folin's Method 673 

Marshall's Method 674 

Ureters. See Kidneys and Ureters. 

Diseases of. 
Ureters and Bladder, Examination of. 

Cystoscopy 675 

Varieties of Cystoscope 675 

Preparation of the Cystoscope for 

Use 675 

Preparation of the Patient 676 

General Anesthesia 676 



CONTENTS. 



XIX 



PAGE 

Ureters and Bladder, Examination of, 
Cystoscope (continued). 

Technique of Cystoscopy 676 

Uses of Cystoscopy 677 

Ureteral Catheterizaion 678 

Urinary Segregation 678 

Urethane 679 

Physiological Effects 679 

Poisoning by Urethane 679 

Treatment of Poisoning 679 

Therapeutic Uses 679 

Urethra. See Urinary and General Sys- 
tems, Surgical Diseases of. 
Urinalysis. See Index under titles of 
various abnormal conditions 
of Urine : Albuminuria. Lac- 
tosuria, Tyrosinuria, etc. 
Urinary and Genital Systems, Surgical 

Diseases of 679 

Diseases of the Urethra 679 

Anomalies of the Urethra 679 

Congenital Occlusion 679 

Congenital Stricture 679 

Urethral Pouches 679 

Epispadias 680 

Treatment 680 

Hypospadias 680 

Treatment 680 

Injuries of the Urethra 681 

Rupture of the Urethra 681 

Symptoms 681 

Treatment 682 

Foreign Bodies and Calculi in the 

Urethra 683 

Symptoms 683 

Diagnosis 683 

Treatment 683 

Gonorrhea 684 

Definition 684 

Symptoms 684 

Acute Gonococcal Urethritis . . . 684 
Chronic Gonococcal Urethritis . 685 

Diagnosis 685 

Complications 686 

Prophylaxis 686 

Abortive Treatment 687 

Repressive Treatment 687 

Treatment of Chronic Gonorrhea . 691 

Gonorrhea in Women 692 

Urethra 693 

Treatment 693 

Vagina and Vulva 693 

Symptoms 693 

Treatment 693 

Periurethritis and Urethral Fistula . 694 

Treatment 694 

Cowpcritis 695 

Treatment 695 

Non-gonorrheal Urethritis 695 

Symptoms 695 

Diagnosis 695 

Treatment 695 

Stricture of the Urethra 695 

Varieties 696 

Symptoms 696 

Diagnosis 696 

Etiology_ 697 



PAGE 

Urinary and Genital Systems, Surgical 
Diseases of, Diseases of the Urethra, 
Stricture of the Urethra {continued) . 

Treatment 697 

Dilatation 697 

Urethrotomy 698 

Internal Urethrotomy 698 

External Urethrotomy 699 

A. With a Guide — Syme's 
Operation 699 

B. Without a Guide— Peri- 
neal Section 699 

Urethral, Urinary, or Catheter 

Fever 699 

Symptoms and Etiology 699 

Acute Urinary Septicemia 699 

Chronic Urinary Septicemia .... 700 
Treatment '. 700 

Chancroid 700 

Definition 700 

Symptoms 700 

Etiology 701 

Diagnosis 701 

Complications 701 

Treatment 702 

Tumors of the Urethra 702 

Treatment 703 

Diseases of the Prostate 703 

Anomalies 703 

Injuries of the Prostate 703 

Etiology 703 

Treatment 703 

Foreign Bodies and Calculi in the 

Prostate 704 

Symptoms 704 

Etiology 704 

Diagnosis 704 

Treatment 704 

Acute Prostatitis 704 

Symptoms 704 

Etiology 705 

Treatment 705 

Chronic Prostatitis 706 

Symntoms 706 

Diagnosis 706 

Etiology 707 

Treatment 707 

Abscess of the Prostate 708 

A Symptoms 708 

Etiology 7aS 

Treatment 708 

Prostatorrhea 70S 

Symptoms 708 

Etiology 709 

Treatment 709 

Atrophy of the Prostate 709 

Hypertrophy of the Prostate 7t)9 

Symptoms 709 

Diagnosis 710 

Etiology and Pathology 711 

Prognosis 712 

Treatment 712 

Operatiye Treatment 713 

Vasectomy 713 

Castration 714 

Galvanocauterization 714 

A. Bottini's Operation .... 714 



XX 



CONTEXTS. 



PAGE 

'Urinary and Genital Systems, Surgical 
Diseases of, Diseases of the prostate, 
Hypertrophy of the prostate, Operative 
Treatment, Galvanocauterization (con- 
tinued). 

B. Chetwood's Operation . . 714 

Cystostomy 714 

Prostatectomy 715 

Suprapubic Prostatectomy . . . 715 
Perineal Prostatectomy . . . 715 

A. Median 715 

B. Extra-urethral 715 

Tuberculosis of the Prostate 716 

Symptoms ' 716 

Diagnosis 716 

Etiology 716 

Treatment 716 

Tumors of the Prostate 717 

Cysts 717 

Carcinoma 717 

Symptoms 717 

Diagnosis 717 

Treatment 717 

Sarcoma 718 

Treatment 718 

Diseases of the Bladder 718 

Anomalies 718 

Treatment 718 

Exstrophy of the Bladder 718 

Treatment 718 

Retention of Urine 719 

Definition 719 

Symptoms 719 

Etiology 719 

Complications and Sequelae 720 

Treatment 720 

Rupture of the Bladder 722 

Symptoms and Diagnosis 722 

Treatment 723 

Cystocele 723 

Treatment 723 

Foreign Bodies in the Bladder .... 723 

Symptoms 724 

Diagnosis 724 

Treatment 724 

Vesical Calculus 724 

Symptoms 725 

Diagnosis 726 

Treatment 726 

Lithotomy 727 

Technique of Litholapaxy 727 

Technique of Lithotomy 728 

Perineal Lithotomy, Lateral . . 729 

Median .......' 730 

Suprapubic Lithotomy 730 

Tuberculosis of the Bladder 731 

Symptoms 731 

Diagnosis 732 

Treatment 732 

Tumors of the Bladder 733 

Varieties 733 

Symptoms 733 

Etiology and Pathology 733 

Diagnosis 734 

Prognosis 734 

Treatment 734 

Ulcer of the Bladder 735 



PAGE 

LIrinary and Genital Sysems, Surgical 
Diseases of, Diseases of the I'laddcr, 
Ulcer of the Blader (continued). 

Diagnosis 736 

Treatment 736 

Varicose Veins of the Bladder 736 

Treatment 736 

Fistula of the Bladder 736 

Treatment 736 

Diseases of the Seminal Vesicles 736 

Anomalies 736 

Wounds 736 

Concretions 737 

Treatment 737 

Acute Seminal Vesiculitis 737 

Symptoms 737 

Diagnosis 737 

Treatment 737 

Chronic Seminal Vesiculitis 737 

Symptoms 737 

Diagnosis 737 

Treatment 737 

Tuberculosis of the Seminal Vesicles. 738 

Symptoms 738 

Diagnosis 738 

Treatment 738 

Tumors 738 

Diseases of the Spermatic Cord 738 

Anomalies 738 

Wounds 738 

Treatment 738 

Torsion 739 

Inflammation 739 

Treatment 739 

Hydrocele of the Cord 739 

Treatment 739 

Solid Tumors 739 

Urobilinuria 740 

Urticaria 740 

Definition 740 

Synonyms 740 

Symptoms 740 

Urticaria Papulosa (Lichen Urti- 
catus) 740 

Urticaria Bullosa 740 

Urticaria Nodosa (U. Tuberosa ) .. 740 

Urticaria Hemorrhagica 740 

Urticaria Intermittens 740 

L^rticaria Perstans 740 

Urticaria Pigmentosa 741 

Diagnosis 741 

Etiology 741 

Pathology 741 

Prognosis 741 

Treatment 741 

Litems, Diseases of 742 

Malformations 742 

Rudimentary Uterus 742 

Abscess of the Uterus 742 

Embryological Malformations 742 

One-horned Uterus 742 

Two-horned Uterus 742 

Double Uterus 742 

Two-chambered Uterus 742 

Fetal Uterus 743 

Infantile Uterus 743 

Puerile Uterus 743 



CONTENTS. 



XXI 



PAGE 

Uterus, Diseases of, Embryological Mal- 
formations (continued). 

Puerile Cervix 743 

Symptoms and Diagnosis 743 

Treatment 743 

Stenosis of the Cervix 744 

Symptoms 744 

Diagnosis 744 

Prognosis 744 

Treatment 744 

Laceration of the Cervix 745 

Symptoms and Diagnosis 745 

Pathology 745 

Treatment 745 

Displacements of the Uterus 746 

Etiology 746 

Anteflexion and Anteversion 748 

Symptoms 748 

Diagnosis 748 

Treatment 748 

Retroflexion and Retroversion 749 

Symptoms 749 

Diagnosis 749 

Treatment 749 

Prolapse and Procidentia 750 

Symptoms 750 

Diagnosis 750 

Treatment 750 

Inversion of the Uterus 751 

Symptoms and Diagnosis 751 

Prognosis 752 

Treatment 752 

Tuberculosis of Uterus and Adnexa . . 753 

Tuberculosis of the Body of Uterus . 753 

Symptoms and Diagnosis 753 

Treatment 753 

Tuberculosis of the Cervix 753 

Symptoms 753 

Prognosis 753 

Treatment 753 

Tumors of the Uterus 753 

Myoma of the Uterus 753 

Symptoms 754 

Diagnosis 754 

Etiology 755 

Pathology 755 

Prognosis 755 

Treatment 755 

Carcinoma of the Uterus 757 

Cervix Uteri 757 

Squamous-cell Carcinoma 757 

Cylindrical-cell Carcinoma ... 75S 

Symptoms and Diagnosis 758 

Prognosis 759 

Treatment 759 

Corpus Uteri 760 

Symptoms 760 

Diagnosis 760 

Prognosis 760 

Treatment 761 

Dcciduoma Malignum 761 

Treatment 761 

Sarcoma of the Uterus 761 

Sarcoma of the Cervix 761 

Symptoms and Diagnosis 761 

Sarcoma of the Endometrium .... 761 

Interstitial Sarcoma 762 



PAGE 

Uterus, Diseases of. Tumors of the 
Uterus, Sarcoma of the Uterus, Inter- 
stitial Sarcoma {continued). 

Symptoms 762 

Diagnosis 762 

Treatment 762 

Uva Ursi 762 

Preparations and Doses 762 

Physiological Action 762 

Therapeutic Uses 762 

Uveal Disorders. See Iris, Ciliary Body 

and Choroid. 
Uvula. See Pharynx and Tonsils, Dis- 
eases of. 

Vaccination. See Varioloid and Vac- 
cination. 

Vagina and Vulva, Diseases of 763 

Acute Vulvovaginitis 763 

Symptoms 763 

Etiology 763 

Treatment 764 

Chronic Vulvitis 764 

Follicular Vulvitis 764 

Glandular Vulvitis 765 

Treatment 765 

Gonorrheal Vulvovaginitis 765 

Diagnosis 765 

Etiology 766 

Treatment 766 

Infectious Vaginitis 766 

Tuberculous Vulvovaginitis 766 

Symptoms 766 

Treatment 767 

Diphtheritic Vulvovaginitis 767 

Treatment 767 

Puerperal Vulvovaginitis 768 

Treatment 768 

Eczematous Vulvovaginitis 768 

Etiology 768 

Treatment 768 

Leucorrhea 769 

Symptoms 769 

Etiology 769 

Treatment 769 

Atrophy of the Vagina and Vulva . . . 770 
Hypertrophy of the Vagina and Vulva 770 

Treatment 770 

Prolapse of the Vagina 771 

Treatment 771 

Vaginismus 771 

Treatment 771 

Vaginal Fistulae 772 

Treatment 772 

Mayo's Technique 772 

Tumors of the Vagina and Vulva .... 773 

Benign 773 

Malignant 773 

Hcrnije 773 

Treatment 774 

Cysts 774 

Treatment 774 

Hematomata 774 

Treatment 775 

Miscellaneous Growths 775 

Treatment 775 

Fungous Growths 775 



xxn 



CONTENTS. 



PAGE 

Vagina and Vulva, Diseases of, Tumors 
of the Vagina and Vulva. Fungous 
Growths (coiilinucd) . 

Treatment 775 

Foreign Bodies 775 

Treatment 775 

Malignant Growths 775 

Treatment 776 

Congenital Absence 776 

Treatment 776 

Adhesions 777 

Acquired Occlusion 777 

Varicocele 777 

Treatment 777 

Parasitic Vulvitis 777 

Treatment 777 

Kraurosis Vulva; 778 

Treatment 778 

Pruritus Vulvae 778 

Treatment 778 

Vaginoperineal Injuries. See Pregnancy 
and Parturition, Disorders of. 

Vagotonia and Sympatheticotonia 780 

Symptoms 780 

Pathology 780 

Treatment 780 

Valerian 780 

Preparations and Doses 780 

Physiological Action 780 

Therapeutics 781 

Valvular Diseases of the Heart. See 
Endocardium and Heart, 
Diseases of. 

Varicella 781 

Definition ■ • 781 

Symptoms 781 

Diagnosis 781 

Etiology 782 

Prognosis 782 

Treatment 782 

Varicocele. See Penis and Testicles, 
Diseases and Injuries of. 

Variola (Smallpo.x) 782 

Definition 782 

Symptoms 782 

Special Forms 783 

Diagnosis 783 

Scarlatina 783 

Measles 783 

Typhoid Fever 783 

Influenza 783 

Meningitis 783 

Cerebrospinal Meningitis 783 

Etiology 783 

Prophylaxis 784 

Treatment 784 

Varioloid and Vaccination 785 

Varioloid 785 

Vaccination 785 

Technique 785 

Prevention of Infection 786 

Acupuncture Method 786 

Symptoms 787 

Revaccination 787 

Efficacy of Vaccination 787 

Vascular System, Disorders of 788 

Raynaud's Disease 788 



PAGE 

Vascular System, Disorders of, Raynaud's 
Disease (continued). 

Symptoms 788 

Etiology and Pathogenesis 788 

Treatment 789 

Erythromelalgia 790 

Symptoms 790 

Etiology and Pathology 790 

Treatment 790 

Acroparesthesia 791 

Symptoms 791 

Etiology and Pathology 791 

Pathogenesis 791 

Treatment 792 

Vasomotor Ataxia 792 

Symptoms 792 

Diagnosis 793 

Treatment 793 

Traumatic Neuroses 794 

Pathogenesis 794 

Symptomatology 795 

Vascular System, Surgical Diseases of . 797 

Acute Arteritis 797 

Symptoms 797 

Treatment 797 

Phlebitis 797 

Symptoms 797 

Etiology 797 

Prognosis 797 

Treatment 798 

Venous Varix, or Varicose Veins 798 

Symptoms 798 

Etiology 798 

Pathology 798 

Treatment 798 

Palliative Measures 798 

Radical Treatment 798 

Hemorrhage 799 

Symptoms 799 

Treatment 799 

Injuries and Wounds of Vessels 800 

A. Arteries 800 

Contusion 800 

Rupture 800 

Punctured Wounds 800 

Incised Wounds 800 

B. Veins 800 

Treatment 800 

Secondary Hemorrhage 801 

Venous Hemorrhage 801 

Thrombosis 801 

Varieties 801 

Symptoms 801 

Etiology 801 

Pathology 802 

Treatment 802 

Phlegmasia Alba Dolens 802 

Symptoms 802 

Diagnosis 803 

Etiology 803 

Pathology 803 

Complications 803 

Sequelc-e 803 

Prognosis 803 

Treatment 803 

Vasomotor Neuroses. See Vascular Sys- 
tem, Disorders of. 



CONTENTS. 



xxni 



PAGE 

Veins, Disorders of. See Vascular 

System. 

Venesection and Blood Transfusion .... 803 

Venesection 803 

Technique 803 

Indications 804 

Blood Transfusion 804 

Technique 804 

Indications 805 

Venomous Bites. See Index. 

Veratrum 805 

Preparations and Doses 805 

Physiological Action 805 

Untoward Effects and Poisoning 806 

Treatment of Poisoning 806 

Therapeutics 806 

Veronal 807 

Physiological Action 807 

Poisoning by Veronal 807 

Treatment of Poisoning by Veronal . 807 

Therapeutic Uses 807 

Vitamines 808 

Warts. See Skin, Surgical Diseases of... 

Water (Hydrotherapy) 809 

Reaction . 809 

Temperature of Baths 809 

Hydrotherapeutic Measures 809 

The Cold Pack 809 

Evaporation Bath 809 

The Cold Bath 810 

The Half-bath of Priessnitz 810 

The Spray Bath 810 

The Ablution or Wet-mit Friction . 810 

The Drip Sheet or Sheet Bath 810 

Sponging 811 

The Oil Rub 811 

The Scotch Rub 811 

Salt Rub or SaU Glow 811 

Ice Rub or Ice Ironing 811 

Alcohol Rub 811 

Douches 811 

Cold Applications 812 

Hot Applications 812 

Needle Douche or Spray ; Circular 

Douche 812 

Cold Douche 812 

Spinal Douche 812 

Alternating Hot and Cold Douches 

(Scotch Douche) 812 

Head Douches 812 

Rain Douche 812 

Fan Douche 812 

Filiform Douche 812 

Perineal Douche 812 

Aix Douche 813 

Affusions 813 

Continuous Baths 813 

The Warm Full Bath 813 

Prolonged Warm Baths 813 

Warm Baths of Short Duration .... 813 

The Hot Rath 813 

Special Baths 813 

The Brand Bath 813 

The Turkish Bath 813 

The Russian Bath (Diaphoretic) ... 814 
Vapor or Sweating Bath 814 



PAGE 

Water (Hydrotherapy), Special Baths 
(cotitinucd) . 

Foot-bath 814 

Medicated Baths 814 

Alkaline Bath 814 

Pine-needle Bath 814 

Sulphur Bath 814 

Packs 814 

Cold Wet Pack 814 

Hot Wet Pack 814 

Dry Hot Pack 814 

Compresses 814 

Cold Compress 814 

Ice Compresses 815 

Hot Compresses (Fomentations) ... 815 
Weil's Disease. See Liver and Gall-blad- 
der : Acute Infectious Jaun- 
dice. 
Wen. See Skin, Surgical Diseases of. 
Whooping-ceugh. See Pertussis. 
Wintergreen. See Gaultheria. 
Witchhazel. See Hamamelis. 
Worms. See Parasites, Diseases Due to. 

Wounds, Septic and Sepsis 815 

Prophylaxis 815 

Commonly Used Antiseptics 815 

Sodium Hypochlorite or Dakin-Car- 

rel Solution .- . . 816 

Daufresne's Technique 816 

Wound Excision and Primary Suture . 819 

Delayed Primary Suture 820 

Secondary Suture 820 

General Infections; Sepsis 822 

Toxemia or Sapremia 822 

Septicemia 823 

Pyemia 824 

Etiology and Pathology 825 

Toxemia or Sapremia 825 

Septicemia, Sepsis, Septic Infec- 
tion 826 

Pyemia 826 

Prognosis 826 

Treatment 827 

Local Measures 827 

Dichloramine-T 828 

Flavine 830 

Brilliant Green 830 

Bismuth Iodoform Paste 831 

Serums and Vaccines 833 

Babcock's Method 833 

General Measures 834 

Puerperal Sepsis 835 

Symptoms 835 

Etiology 836 

Diagnosis 836 

Treatment , 837 

Wounds, Venomous. See Wounds and 
Stings. 

Xanthoma 837 

Etiology 837 

Pathology 837 

Prognosis 838 

Treatment 838 

Xanthoma Diabeticorum 838 

Pathology 838 

Prognosis 838 



XXIV 



CONTEXTS. 



PAGE 

Xanthoma Diabeticorum (continued). 

Treatment 838 

X-ravs and Radium 838 

X-rays 838 

Physiological Action 838 

Untoward Effects 839 

Therapeutic Dosage 839 

Apparatus 839 

Estimation of Dosage 840 

Filters 841 

Therapeutic Uses 841 

Diseases which Benefit by X-ray 

Stimulation 841 

Diseases which Benefit by Reduc- 
tion of Tissue Activity .841 

Diseases which Benefit by Destruc- 
tion of Cells 841 

Radium 841 

Physiological Action 841 

Therapeutic Uses 842 

Yaws 843 

Synonyms 843 

Symptomatologv' 843 

The Primary or Prodromal Stage .. 843 
The Secondary or Granulomatous 

Stage 843 

The Tertiary Stage 843 

Infection 843 

Treatment 843 

Prophylaxis 843 

Yellow Fever 843 

Symptomatology 844 



PAGE 

Yellow Fever, Symptomatology (con- 
tinued). 

Fulminant Cases 844 

Diagnosis 844 

Etiology 845 

Pathology and Pathogenesis 845 

Prognosis 845 

Prophylaxis 845 

Treatment 846 

Yohimbine 846 

Physiological Action 846 

Untoward Effects 846 

Therapeutic Uses 846 

Zinc 847 

Preparations and Doses 847 

Irritant (Soluble) 847 

Mild (Insoluble) 847 

Physiological Action 848 

Acute Poisoning by Zinc Salts 848 

Chronic Poisoning 848 

Treatment of Acute Poisoning 849 

Therapeutics 849 

Gastrointestinal Disorders 849 

Respiratory Disorders 849 

Nervous Disorders 849 

Cutaneous Disorders 850 

Catarrhal Disorders 850 

Zingiber 850 

Preparations and Doses 850 

Physiological Action 850 

Therapeutic Uses 850 

Zona. See Herpes Zoster. 



/ 



SAJOUS'S 
ANALYTIC CYCLOPEDIA 
of PRACTICAL MEDICINE 



R 



R H E U M AT I S M. — A group of 
affections, sometimes of parasitic 
origin, characterized by pain and 
swelling of the joints and muscles, 
and which may be acute or chronic. 
Under this term may be grouped 
rheumatic fever, muscular rheuma- 
tism, and various joint manifestations 
dependent upon specific infections 
such as gonorrhea, scarlatina, diph- 
tlieria, etc. Of these conditions, the 
first three will be considered seriatim 
in this article. 

Rheumatoid arthritis or, according 
to the newer classification of Gold- 
thwait, (1) chronic atrophic arthritis, 
and (2) chronic hypertrophic ar- 
thritis, have been considered in the 
article on Joints, Surgical Diseases 
OF, in vol. vi. 

RHEUMATIC FEVER. 

Rheumatic fever {acute or subacute 
rheumatism; acute articular rheuma- 
tism), is an acute and subacute infec- 
tious, febrile disease, characterized 
by migratory, multiple artl^ritis, sweat- 
ing, and a tendency to complicating 
inflammation of the serous membranes 
and the fibrous tissues, and to re- 
currence. 

SYMPTOMS. — Rheumatic fever 
rarely presents marked i)rodromal 



symptoms, but ordinarily the patient 
feels weary and ill for from one to 
three days. Occasionally fugitive 
pains, sore throat, or otitis media 
precede the onset of the disease. 
The symptoms of the acute affection 
then set in suddenly with chills, which 
may be repeated once or twice. 
Fever appears and the temperature 
rises to 39° or 40° C. (102.2° or 
104° F.) ; the pulse and respiration 
are accelerated, the tongue furred; 
there is no appetite, but thirst is 
marked. The urine is scanty, highly 
acid, and loaded with urates, which 
give it a dark-red color and rapidly 
precipitate; the specific gravity of the 
urine is high, and it is not rare to ob- 
serve albuminuria on the first days of 
the disease. Chemical examination 
demonstrates that urea as well as 
uric acid is present in excessive 
quantity. Hemoglobinuria, pepto- 
nuria, urobilinuria, and cystinuria 
have sometimes been observed. 

The skin is covered with abundant 
perspiration and numerous sudamina 
and miliaria often appear on it. The 
sweat is acid and of a peculiar odor. 

Simultaneously with the fever the 
characteristic signs of rheumatic ar- 
thritis appear, generally in the articu- 

(1) 



RHEUMATISM (LEVISON AND SAJOUS). 



lations of the foot or the knee. Fre- 
quently the affection begins in the 
ankle-joint, and after some days the 
process also invades the knee, the 
shoulder, the elbow-joint, and the 
wrist. Occasionally the affection 
begins in the joints of the upper ex- 
tremities. This, when it is the case, 
ordinarily occurs in persons occupied 
in hard bodily work. The larger 
joints are most frequently affected,' 
but sometimes the small joints of the 
fingers and toes are also involved, 
especially in children. A single joint 
rarely continues to be the seat of 
trouble for more than four or five 
days ; the affection then more or less 
suddenly disappears, commonly dur- 
ing the night, and one or more other 
joints are attacked in turn. At one 
time several joints may be involved 
to a varying extent. In very severe 
cases almost all joints may be af- 
fected simultaneously, and even the 
articulations of the jaws, the spine, 
and the ribs may be painful and swol- 
len. Ordinarily rheumatic fever at- 
tacks several articulations, but mon- 
articular acute rheumatism has also 
been observed. 

According to statistics, the locali- 
zation of the disease in the different 
joints is as follows : Ankle, 27.8 per 
cent. ; knee, 17.9 per cent. ; wrist, 9.6 
per cent. ; shoulder, 6.2 per cent. ; hip, 
4.1 per cent. ; metatarsus, Zj per 
cent. ; elbow, 2.2 per cent. ; metacar- 
pus, 1.2 per cent.; toes, 0.8 per cent.; 
fingers, 0.8 per cent. 

Analyzing 100 cases of so-called 
"rheumatism," the author found that 
these included 44 cases of arthritis 
and 3 of muscular rheumatism to 
which the term "rheumatism" might 
be fairly applicable. Thirty of the 
44 patients gave a history of gonor- 
rhea. Among the 53 incorrectly 



diagnosed cases there were 18 of 
syphilis, with a positive Wassermann, 
8 of neuritis, 4 of tuberculosis, 4 of 
flat foot, 3 typical cases of pellagra, 
2 each of neurasthenia, arterioscle- 
rosis, sciatica, and tabes, and 1 each 
of chronic nephritis, chronic gas- 
tritis, muscular atrophy, malaria, per- 
nicious anemia, and myelitis. Deade- 
rick (South. Med. Jour., Dec, 1918). 

The affected joints are very painful 
and swollen ; the overlying skin is 
red, hot, tense, and edematous, while 
pressure upon it leaves an impression 
which remains visible for some time. 
Swelling of the joint is caused prin- 
cipally by edema of the skin and 
ligaments, but occasionally also by 
an effusion in the articulation itself. 
Upon moving the diseased articula- 
tion a crackling sound is sometimes 
heard ; this is commonly caused by 
the inflammatory changes in the ten- 
dons and their synovial membranes. 
Moving and even touching the af- 
fected joints is very painful to the 
patient; in severe cases the pain may 
be occasioned by very small commo- 
tions, e.g., by walking over the floor 
of the sick-room. The pain seems to 
be localized in the tendons and the 
muscles in the proximity of the joint. 
When the patient is induced to keep 
completely quiet, slight movements 
of the diseased joint may be passively 
executed without causing any pain, 
whereas the most trifling active 
movement is accompanied by ex- 
cruciating pain. 

The skin over the affected articu- 
lation shows increased sensibility to 
changes of temperature, but a dimin- 
ished sensibility to faradic irritation. 

Of diagnostic importance in the 
cases in which they are present are 
small nodules — "rheumatic nodules" 
— 1 to 4 mm, in diameter, generally 



RHEUMATISM (LEVISON AND SAJOUS). 



not tender, appearing- in areas where 
bones underlie the skin or in the 
synovial sheaths of tendons. These 
occur especially in children. They 
may disappear rapidly or only after 
some months. Fibrosis may occur in 
them. 

The temperature of the patient is 
elevated in proportion to the number 
of the affected articulations ; in un- 
complicated cases it seldom rises 
above 39° to 40° C. (102.2° to 
104° F.), but it may also oscillate be- 
tween 38° and 39° C. (100.4° and 
102.2° F.). Acid sweats often take 
place consentaneously with remis- 
sions in the temperature. 

One of the earliest and most con- 
stant and obscure symptoms of rheu- 
matism in children is a persistent low 
fever, dropping- daily to normal, occa- 
sionally below, and seldom going 
above 100° F. The child usually feels 
well, looks well, and the condition is 
only accidentally discovered. The 
first suggestion occurs after an illness 
during which time there has been ele- 
vation of temperature, but as the 
other symptoms clear up the tempera- 
ture chart reveals the persistence of 
a small amount of unaccountable 
fever. A complete examination may 
disclose no symptoms other than 
slight acceleration of the heart on 
exertion. One naturally thinks of tu- 
berculosis, but gets a negative von 
Pirquet. Poynton considers this tem- 
perature an important diagnostic 
symptom of very early rheumatic in- 
fection. J. A. Colliver (Arch, of 
Pediat, Jan., 1914). 

The pulse is soft and usually above 
100 in rate. Evidences of toxemia, 
such as coated tongue, constipation, 
and splenic enlargement are likely to 
be observed. 

The duration of rheumatic fever 
varies from some days to several 
weeks or even months ; it is liable to 



remissions and exacerbations, and, 
especially when the patient leaves the 
bed or the sick-room too soon, exacer- 
bations are frequently observed. In 
some cases, the fever having- de- 
clined, one or more joints remain 
swollen and painful for a long time. 
A critical decline of the temperature 
is rarely observed. 

When the joint swellings subside 
the cuticle commonly cracks and 
peels off in small scales. As many 
red blood-corpuscles become de- 
stroyed during a severe attack of 
rheumatic fever, the patients get 
pale and weary. The anemia often 
continues for a long- period after re- 
covery from the disease itself. Leu- 
cocytosis, up to a maximum of 20,000, 
has been observed to develop early in 
the rheumatic attack and to decline 
with equal rapidity during- con- 
valescence. 

Some authors refer to a larval form 
of rheumatic fever, characterized by 
neuralgia of, e.g., the trifacial or the 
sciatic nerve, accompanied by high 
fever, but without involvement of the 
joints, and yielding rapidly to the use 
of salicylates. During an epidemic of 
rheumatic fever endocarditis or peri- 
carditis with high fever is sometimes 
observed in patients who do not suf- 
fer from any involvement of the ar- 
ticulations ; such cases have been 
denominated polyarthritis rhcumatica 
sine arthritide. 

COMPLICATIONS.— These are 

very frequent and aft'ect especially 
the heart and the nervous system. 
Verrucose and even ulcerative endo- 
carditis is observed in a large pro- 
portion of cases, especially when the 
fever is high and many joints are 
affected. Pericarditis is not quite so 
frequently observed. Endocarditis 



RHEUMATISM (LEVISON AND SAJOUS). 



has been estimated to occur in about 
20 per cent, of all cases, and pericar- 
ditis in about 14 per cent. ; but these 
proportions vary, the epidemics of 
rheumatic fever differing very much 
in regard to severity and frequency 
of complications. Bosanquet, in a 
series of 450 cases, noted endocar- 
ditis in 28 per cent, of the males and 
33 per cent, of the females, and some 
observers place the incidence of endo- 
carditis at 50 to 75 per cent. The 
likelihood of endocarditis is increased 
by youth of the patient and where 
preceding attacks have occurred. 
The mitral valve is that oftenest in- 
volved. Pericarditis is observed in 
the majority of the cases ending 
fatally, and may be fibrinous, sero- 
fibrinous, or purulent. 

In almost all cases some dilatation 
of the right heart due to toxic myo- 
carditis, is found. A murmur heard 
over the heart is thus often not due 
to endocarditis, but to cardiac dilata- 
tion (or to anemia). In consequence 
of endocarditis, the myocardium may 
also be affected either by simple ex- 
tension through contiguity or by em- 
boli. A condition of complete car- 
diac inflammation or pancarditis may 
occur. Slight weakening of the myo- 
cardium may be manifested by gen- 
eral weakness, attacks of pain, or 
tachycardia. The symptoms of endo- 
carditis and pericarditis are discussed 
elsewhere in this work. 

D. B. Lees describes the cardiac 
complications of rheumatism in child- 
hood as follows : The first indication 
of endocarditis is a systolic murmur 
at the apex. Often the second sound 
becomes doubled, after a time, the 
doubling being heard only in the 
apex region, different from the dupli- 
cated pulmonary sound of advanced 



mitral stenosis. The first element of 
the second sound always remains 
sharp and short as long as it is 
audible at all. The second element 
may be substituted by a short blow- 
ing, early diastolic or middiastolic 
murmur. At a later stage there may 
be at the apex a presystolic murmur, 
followed by a longer and louder sys- 
tolic. This presystolic murmur is 
blowing in character, usually short, 
common in children after a rheumatic 
attack, and generally accompanied 
by evidences of great dilatation of the 
heart. Care should be taken not to 
consider a soft, double sound at the 
base an evidence of commencing 
aortic disease. It is often the first 
indication of pericarditis. 

While in adults the disease spends 
itself chiefly upon the joints, in the 
child it has a much greater tendency 
to attack the heart; the joint involve- 
ment in the latter is often so slight 
as to be overlooked, yet the cardiac 
• involvement may be severe. Ton- 
sillitis is in the child a frequent pre- 
cursor of rheumatism, while chorea 
is at times a sequel. Cardiac involve- 
ment might come w^ithin 24 hours of 
the beginning of the rheumatic at- 
tack and its discovery depends upon 
a careful routine study of the heart. 
The mitral lesions thus caused are 
capable of complete recovery, though 
the aortic lesions practically never 
recover. D. Riesman (Trans. Phila. 
Co. Med. Soc; Med. Rec, Apr. 16, 
1921J. 

Rheumatism in the child can be 
discovered at the age of 5 years, pos- 
sibly earlier. Earlier signs of the 
disease are an incessant restlessness, 
a constantly accelerated pulse rate, 
often reaching 100 or over, and very 
frequently a constant fever of a little 
over 99° F. (37.2° C.) to a little more 
than 100° F. (37.8° C). That such 
a rise of temperature and of pulse 
rate are not due to nervous excite- 



RHEUMATISM (LEVISON AND SAJOUS). 



merit is proved by their being found 
for years in the same child and 
always at about the same level for 
any one child. This observation is 
based upon over SOOO temperature 
r-ecords. M. H. Williams (Lancet, 
June 19, 1915). 

Very dangerous and rather fre- 
quent are the complications involving- 
the brain. In some cases the symp- 
toms are only caused by hyperpy- 
rexia; when the temperature rises to 
41° or 42° C. (105.8° or 107.6° F.) 
or even to 43° C. (109.4° F.), when 
sweating is very profuse, and signs 
of endocarditis develop, there is im- 
minent danger of cerebral rheuma- 
tism. When symptoms of meningitis 
occur, they are not necessarily due 
to actual inflammation of the menin- 
ges, but may be caused by hemor- 
rhage, edema, or hyperemia. A 
uremic condition of the blood may 
also lead to cerebral symptoms. 

Cerebral rheumatism may manifest 
itself in different ways : — 

1. When it is foudroyant the pa- 
tient is suddenly seized with agita- 
tion ; although previously unable to 
make a movement without extreme 
pain, he now leaves the bed and 
walks about, speaks and cries, and 
suddenly collapses and dies. The 
temperature ranges from 42° to 43° 
C. (107.6° to 109.4° F.) and often 
even exceeds these levels after death. 

2. An acute form of cerebral rheu- 
matism is more often observed. 
There is likewise high fever; the 
delirium commences more quietly, 
but after a little time the patient be- 
comes agitated, and may have epi- 
leptiform seizures, these symptoms 
being followed by profound coma and 
commonly by death. In a few in- 
stances cerebral symptoms are ob- 
served with a temperature, not ex- 



ceeding 39° C. (102.2° F.). The 
pulse rate is proportionate to the 
fever and may reach 120 to 140 per 
minute. The duration of this form of 
cerebral rheumatism is commonly two 
or three days, but may be ten to 
twelve days. Recovery is rare. 

3. The subacute or chronic form of 
cerebral rheumatism appears in the 
later stages of rheumatic fever and 
is ordinarily of a melancholic and 
stuporous character. The patients 
refuse to speak, even to eat, and are 
often harassed with hallucinations. 
They may remain in this condition 
for months, but the affection ordi- 
narily ends in recovery. 

Spinal complications have been 
described, but their existence hasi not 
been proved beyond doubt. The 
peripheral nerves may also be affected 
during rheumatic fever, but far 
oftener such disturbances occur some 
time later, as a sequel. Chorea, mul- 
tiple neuritis, neuralgia, and sciatica 
have been witnessed by trustworthy 
observers. During an epidemic 
Steiner saw 35 cases with disease of 
the peripheral nerves — often in the 
distribution of a single nerve — char- 
acterized by pain and tenderness. 
In 8 of these, swelling of the joints 
was not important, though there was 
tenderness. Steiner claims that the 
nerve pains were due to a perineuritis.^ 

Complications involving the re- 
spiratory organs are not so frequently 
observed. Coryza, tracheobronchitis, 
and laryngitis may be seen during 
the prodromal stage. During the 
acute stage the lungs may be affected 
either by edema or, more rarely, by 
pneumonia, particularly of the migra- 
tory form. Rather frequently the 
pleurae are involved. A\'hcn the peri- 
cardium is affected tlic disease tends 



6 RHEUMATISM (LEVISON AND SAJOUS). 

to spread to the left pleura, which The affection of the joints them- 
consequently is more frequently at- selves may be complicated by sup- 
tacked than the right. Rheumatic purative inflammation leading- to 
pleuritis is characterized by abun- opening of the articulation and to 
dant fibrinous membranes, but scanty pyemia, or ending in ankylosis, 
exudation of serous fluid ; it develops In occasional instances involve- 
very rapidly and gives rise to the ment of the eye occurs w^ith rheu- 
ordinary physical signs of pleurisy matic fever, being manifest in con- 
in a very marked degree. Its dura- junctival congestion or, rarely, iritis, 
tion varies from three to eight days. Some of the diseases of the eye as- 
Sometimes the right pleura is ,at- cribed to the more chronic types of 
tacked while left-sided pleuritis is rheumatism are: iritis and episcleritis 
undergoing resolution. Peritonitis is — which are very frequent — as well 
a rare complication which may be as deep scleritis, keratitis, orbital eel- 
associated with serous pleuritis. lulitis, optic neuritis, choroiditis. 

Tonsillitis is a frequent manifesta- ocular palsy, glaucoma, and opacity 
tion of the prodromal stage, and its of the vitreous (Woodruff), 
bacteria are now considered impor- Chronic nephritis and mental dis- 
tant etiological factors in the develop- ease are among the possible ultimate 
ment of rheumatic fever. sequela of rheumatic fever. 

Albuminuria is almost constantly In children cardiac involvement is 

observed; acute nephritis and hema- relatively more frequent and impor- 

turia may occur. Anuria is a rare tant than in adults and generally 

complication ; it may be caused either leads to a fatal termination, promptly 

by acute nephritis or by emboli from or ultimately. The onset is generally 

an endocarditis. abrupt, sometimes with convulsions. 

Cystitis, hydrocele, and orchitis High fever sets in and anemia rapidly 

have been mentioned by some as becomes pronounced. Joint involve- 

occasional complications. ment is comparatively a less striking 

The cutaneous complications in- feature than in adults, 

elude roseola, urticaria, erythema DIAGNOSIS. — The diagnosis is 

multiforme, herpes facialis, and, more usually easy, the migratory arthritis, 

rarely, erysipelas, gangrene, purpura fever, acid sweats, and infrequency 

with ecchymotic spots or bullse con- of involvement of joints such as the 

taining a serous, bloody, or purulent sternoclavicular, temporomandibular, 

fluid. Hemorrhagic complications intervertebral, and sacroiliac being 

have also been observed in the form characteristic. The thyroid is often 

of melena and metrorrhagia. found enlarged in children, owing ac- 

The muscles in the proximity of cording to Sajous, to a defensive re- 

the aff'ected joints are always painful action of this organ. 

and swollen ; this may also be ob- Enlargement of the thyroid gland 

served in the case of muscles more claimed to be a diagnostic sign of 

distant from the diseased joints. In rheumatism in children In some 

cases it preceded all other manifest 



rare instances true inflammation atid 
abscesses have been observed in the 
muscles. the -rheumatic chain, and in others 



signs of the disease; in others it ap- 
abscesses have been observed in the peared as the fourth or fifth link in 



RHEUMATISM (LEVISON AND SAJOUS). 7 

still it was found to persist along The arthritides accompanying such 

with established chronic endocarditis conditions as scarlet fever and cere- 

after all other rheumatic manifesta- ^rospinal meningitis are commonly 
tions had disappeared. J. R. Clemens . ' • ^ vi 

(Arch, of Pediat., May, 1910). ^^ septic type, With accompanymg 

In children the cardiac phenomena constitutional symptoms of sepsis. 
are paramount, but compression of Acutc Osteomyelitis. — This condi- 
the left lung by the pericardial exu- ^j^j^ jg characterized by grave con- 
date may cause physical signs of g^itutional evidences of sepsis, and 
pneumonia in this lung to occur. The . . . . r ^.^ 
^ , . • ,• 1 ■ 1 v.„ Jo +v,« by especial involvement of the epi- 
most characteristic skin lesion is the .^ t" . , , 

so-called rheumatic nodule, which physis and shaft of one of ^ the bones 

histologically resembles the mihary articulating at the afifected joint. The 

nodule in the heart muscle. These upper extremity of the tibia and the 

are usually few, occasionally enor- j^^^^^. ^^^ ^^ ^j^^ femur are the locali- 

xnous in number and are found ^ies most frequently affected. 

chiefly about the elbows, backs of the ^ , ,• , r 

wrists, near the ankles, and over the Gout.—Gout may be discerned from 

buttocks. D. Riesman (Trans. Phila. rheumatic fever by the fact that it is 

Co. Med. Soc; Med. Rec, Apr. 16, never accompanied by fever of the 

1921). same intensity as prevails in the lat- 

Secondary Infectious Arthritis. — ter disease; by its predilection for the 

Rheumatic fever may be confounded great toe ; by the possible presence of 

with the secondary multiple inflam- uratic deposits in various parts of the 

mations of joints observed in acute body, and by its special occurrence in 

infectious diseases such as scarlatina, the male sex. 

cerebrospinal meningitis, puerperal ETIOLOGY. — Rheumatic fever 

infection, rubeola, diphtheria, etc., tends to attack especially young 

and also with the pseudorheumatic adults, approximately three-fourths 

affections of gonorrhea, syphilis, and of the cases occurring between the 

tuberculosis. In all these affections asfes of 15 and 35. Infants are almost 

the symptoms of the major disorder safe, but no age is entirely exempt, 

are present and facilitate diagnosis. The disease attains its greatest fre- 

In gonococcal arthritis there is a quency between the ages of 20 and 

history of gonorrhea; the joint in- 25 years. 

volvement is generally monarticular, Both sexes are liable to the dis- 

affecting especially the knee and ease ; among adults, men are perhaps 

wrist, and is extremely severe ; con- somewhat more frequently affected 

stitutional symptoms are less marked, than women, Init that is probably on 

and the joint lesions tend to persist account of their greater exposure to 

after the febrile stage. the inclemency of the weather. Be- 

In syphilitic pseudorheumatism the tween the ages of 10 and 15 the dis- 

joint-symptoms are less intense than ease is somewhat more common in 

in rheumatic fever; are not migra- the female than the male sex. An 

tory ; show nocturnal exacerbation of hereditary predisposition seems to 
pain, and yield rapidly to specific exist in some families. Cheadle, 

treatment (though pain is relieved, among 32 consecutive cases, found 
as it is in other forms, by the local evidence of heredity in 70 per cent., 
application of methyl salicylate). and, if chorea and erythema be re- 



8 



RHEUMATISM (LEVISON AND SAJOUS). 



garded as forms of rheumatism, in 
93 per cent. 

Exposure to wet, cold, and abrupt 
temperature changes predisposes to 
rheumatic fever, which is therefore 
commonest in coachmen, laborers, 
sailors, and, among women, in washer- 
women and domestics. The dis- 
ease is frequent only in temperate 
climates, and is not observed in 
tropics or in the arctic regions. 

The exciting cause of the disease is 
now considered to be unquestionably 
an infection. This view is supported 
by the facts that it occurs epidem- 
ically, as well as endemically, and 
that during epidemics the cases ac- 
cumulate in some houses, whereas 
other houses are quite spared. Me- 
teorological conditions do not appear 
to be of great influence on the epi- 
demics of rheumatic fever, which 
have been observed as well in the 
sum.mer as in winter, during dry as 
well as wet seasons. The epidemics 
vary greatly in intensity and dura- 
tion, and occur at irregular intervals. 

It is still doubtful whether rheu- 
matic fever is the product of one 
specific micro-organism or whether 
different species act simultaneously 
or independently as pathogenic fac- 
tors. At all events, the clinical and 
pathological features of the disease 
clearly show its infectious origin. 
That streptococci may produce it has 
been shown by a number of ob- 
servers, who have not only recovered 
these organisms from the blood and 
joints of patients, but, like Schloss 
and Foster, reproduced lesions sug- 
gestive of rheumatic fever in lower 
animals. The organism considered 
to be most likely the actual exciting 
factor, or at least that operative in 
the largest proportion of cases, is the 



Diplococcus rheiintaticus isolated by 
Poynton and Paine, who found it not 
only in the joints and blood, but in 
rheumatic nodules and the urine, and 
with it produced arthritis, valvular 
lesions, etc., in rabbits. This organ- 
ism is distinguishable neither mor- 
phologically, culturally, nor by the 
opsonic and agglutinin reactions 
(Tunnicliffe) from the Streptococcus 
pyogenes, but only by the production of 
rheumatic lesions in animals. Poyn- 
ton and Paine consider their diplo- 
coccus the "only bacterial cause" of 
acute rheumatism. Cole believes it 
imwarranted, however, to recognize 
a distinct variety of streptococcus 
because of its property of produc- 
ing arthritis and endocarditis, as he 
has provoked similar lesions in ani- 
mals with streptococci from various 
sources. This is in accord with the 
present increasing disinclination of 
bacteriologists to believe that sharp 
lines separate similar organisms into 
distinct varieties, and is supported by 
the observations of Rosenow (1914) 
that the affinity of cocci freshly 
isolated from the joints in rheumatism 
for the articulations, endocardium, 
and often also myocardium and vol- 
untarv muscles, which tends to dis- 
appear on cultivation, may be re- 
stored by passage through animals, 
and that other strains of streptococci 
under certain conditions may be 
made to acquire the properties of 
the strains obtained from rheumatic 
cases. 

Five cases have been published to 
date in which the tuberculous nature 
of an articular rheumatism has been 
established beyond question. The 
writer's patient was a girl of 19 who 
had had glandular tuberculosis as a 
child, and later a tuberculous process 
in the lower jaw compelling total re- 



RHEUMATISM (LEVISON AND SAJOUS). 



section. Twelve days after the op- 
eration, moderate fever developed 
with multiple acute swelling of joints. 
The patient died in a few months 
from amyloids. Autopsy showed tub- 
erculous nodules in the synovial mem- 
branes. Melchior (Mitteil. a. d. Grenzg-. 
d. Med. u. Chir., xxii, Nu. 3, 1911). 

Cultures of exudate aspirated from 
the joints in acute rheumatic arthritis 
proved uniformly sterile. Non-hemo- 
lytic streptococci were recovered in 
blood cultures from less than 10 per 
cent, of rheumatic fever patients. 
Similar streptococci were recovered 
from active endocardial lesions in 
only half of the fatal cases. No type 
of streptococcus is constantly asso- 
ciated with acute rheumatic fever. If 
the streptococcus actually is the etio- 
logic agent, the infection occurs 
through various members of the 
viridans group. Swift and Kinsella 
(Arch, of Int. Med., Mar., 1917). 

Report of an acute case in a girl of 
17, with a heart injured by a previous 
attack. A general pericarditis with 
copious effusion developed, and the 
fluid withdrawn by paracentesis showed 
numerous minute diplococci, some in 
the fluid, many more in leukocytes. 
This completely supports the results 
of experimentation concerning the 
micro-organism of rheumatic fever. 
It also indicates that in human rheu- 
matic pericarditis with little effusion 
but with great thickening of pericar- 
dial tissues, the diplococci are shut 
in the necrotic areas but imperfectly 
destroyed, causing the intractable re- 
lapsing cases of childhood. Poynton 
(Brit. Med. Jour., Mar. 29, 1919). 

As for the portals of entry of rheu- 
matic infection, the tonsils demon- 
strajjly play an important, if not ex- 
clusive, role in this direction. Not 
only are the tonsils favorite abodes 
of virulent streptococci, and attacks 
of sore throat a frequent manifesta- 
tion of rheumatism, but ori^anisms 
isolated from the tonsils of rheumatic 
cases have, with considerable con- 



stancy, been observed to induce ar- 
thritis and endocarditis when injected 
into animals. Permanent cure of a 
rheumatic tendency has frequently 
followed removal of the tonsils. Ac- 
cording to some, the gums, the nasal 
mucosa, and the gastrointestinal tract 
are also at times sources of infection. 

The pleurisy of acute rheumatism 
usually yields promptly to the sali- 
cylates, but if it is left untreated, 
serious lesions may be installed. The 
rapid invasion of the pleura, the bi- 
lateral involvement, the association 
with congestion of the lungs and with 
pericarditis without effusion, the com- 
plete subsidence without sequels, the 
fixity and long duration of the pleural 
effusion, its moderate amount, and 
the usually mild character of the 
pains in the chest are its distinguish- 
ing features. J. Mollard and M. 
Favre (Lyon med., May, 1917). 

Peritonitis, appendicitis, bronchitis, 
and pneumonia are sometimes ascrib- 
able to rheumatic infection. 

Micrococcus rheumaticus takes the 
path of least resistance. This may be 
an unhealthy throat, absorption from 
which frequently gives rise to gen- 
eral rheumatic infection, including 
peritonitis and appendicitis, directly 
through the vascular system. Or it 
may be localized in the bronchial 
tubes and give rise to pneumonia, 
with polyarthritis and endocarditis. 
An unhealthy condition of the intes- 
tinal wall may excite to activity the 
rheumatic agent. Congestion of the 
pharynx, palate, and fauces in a child 
with a rheumatic family or previous 
history, or with a rheumatic facies, 
should always be looked on seriously, 
and met with local applications of 
salicylic acid preparations, together 
with sodium bicarbonate, sodium sali- 
cylate, potassium chlorate, and aperi- 
ents. A 5 per cent, to 10 per cent, 
solution of sodium salicylate applied 
to the tonsils, palate, and pharynx 
protects from further contamination; 
a gargle containing 20 to 40 grains 



10 



RHEUMATISM (LEVISON AND SAJOUS). 



(1.3 to 2.6 Gm.) to the ounce (30 c.c.) 
is equally efficacious. Decayed teeth 
should be filled or extracted, and 
the daily use of the tooth-brush and 
antiseptic powder should be insisted 
on. Inhalation for half an hour, three 
times a day, of 10 minims (0.6 c.c.) 
of a solution of equal parts of creo- 
sote and phenol is the best method 
of protecting the pulmonary mucous 
membrane. Sodium salicylate, com- 
bined with sodium bicarbonate and 
rhubarb powder, is by far the best 
protective treatment in cases in which 
there is any indication of excess of 
mucus in the intestine. J. K. Mac- 
kenzie (Brit. Med. Jour., June 1, 
1912). 

A woman of 28 developed subacute 
articular rheumatism and endocarditis 
five months after an infected abor- 
tion. No benefit was procured from 
a month or more of the ordinary 
measures, including the salicylates, 
but after straightening and curetting 
the uterus the temperature dropped 
to normal and rapid recovery fol- 
lowed, signs of mild mitral insuffi- 
ciency, however, still persisting. Ar- 
ticular rheumatism of puerperal origin 
generally settles down in one joint 
after a time — the shoulder in the 
writer's case — and stays there. Pierra 
(Revue mens, de gynec, d'obstet., et 
de pediat., Mar., 1914). 

PATHOLOGY.— In all cases of 
rheumatic fever hyperemia is present 
in the joints ; but as these changes are 
extremely fugacious it is ordinarily 
impossible to demonstrate them at 
autopsy. In more advanced cases the 
synovia is augrnented and shows mi- 
croscopically a great number of poly- 
nuclear cells containing globules of 
fat, resembling pus-cells. In some 
cases the cells are not free, but are 
inclosed in a network of fibrin, ap- 
pearing to the naked eye as small 
flakes. True pus is not found in the 
joints except when other infections 
have invaded the body consentane- 



ously with the specific infection of 
rheumatic fever. The synovial mem- 
brane of the afifected joints is then 
red and swollen, with its capillaries 
engorged with blood; the cells of the 
synovial membrane tend toward mul- 
tiplication, containing 10 to 12 nuclei. 
The cartilage is also involved ; its 
cells multiply and form oblong cap- 
sules containing many secondary 
capsules. The macroscopic result of 
these alterations is that the cartilage 
has lost its natural polish and that 
it is finely striated. These patho- 
logical changes are common to all 
varieties of acute arthritis and are 
not characteristic of rheumatic joint 
afifection. Mainly because of periar- 
ticular involvement, some of the 
rheumatic joints, instead of promptly 
recovering from the acute process, 
mav continue in a condition of sub- 
acute or chronic inflammation. The 
tendons and even the periosteum may 
be attacked, with consequent tender 
local thickenings. 

The rheumatic alterations of the 
endocardium, the pericardium, etc., 
revealed by autopsy present the ordi- 
nary signs of an acute inflammation, 
but nothing which is characteristic 
of rheumatic fever proper. Acute 
dilatation of the heart, according to 
Lees, is much commoner, even in 
slight attacks, than in diphtheria or 
influenza. It is, however, far less 
dangerous. Although in the rheu- 
matic heart there is evidence of fatty 
degeneration of the muscle fibers, 
with interstitial round-cell foci, the 
destruction of the muscle is much 
less pronounced than in the diph- 
therial heart. 

Children are prone to the chronic 
or subacute manifestations of rheu- 
matism because the chief site of the 



RHEUMATISM (LEVISON AND SAJOUS), 



11 



multiplication of the organism and 
the manufacture of the toxins is in 
focal lesions outside the blood- 
stream, while in adults it is in the 
blood itself. The rheumatic nodules 
afiford the typical example of local 
response to rheumatic infection. 
They are usually associated with 
grave cardiac mischief, and the more 
numerous and the larger they are the 
more serious the cardiac involvement. 
While present, they prove the per- 
sistence of the rheumatic infection. 
The lesions found in the heart are 
similar in stru"cture to the subcu- 
taneous nodules, but their duration is 
probably less prolonged. In the meso- 
cardium they are found chiefly in the 
walls of the left ventricle, especially 
near the mitral and aortic valves. In 
pericarditis the nodular lesions may 
be confined to a small area or scat- 
tered all over the pericardium. In 
endocarditis the nodules are suben- 
dothelial, and are situated mostly at 
the upper part of the left ventricle, 
especially in the mitral valve. Gos- 
sage (Pediatrics, Apr., 1912). 

Greater attention should be given 
to the various types of acute aneu- 
risms and their relations to acute 
rheumatic fever. The almost con- 
stant presence of some inflammatory 
reaction in the ascending limb of the 
aorta should be recognized as an as- 
sociated conditi®n in this disease. 
Klotz (Jour, of Pathology and Bac- 
teriology, Oct., 1913). 

During the course of rheumatic 
fever the blood contains much more 
fibrin than normal. 

PROGNOSIS.— The prognosis is 
rather good as regards life, as very 
few cases end fatally (0.3 per cent.). 
Usually the disease terminates in two 
to six weeks without having caused 
permanent injury to the joints in- 
volved. Complications, particularly 
those involving the heart, are, how- 
ever, frequent and often lead to 
serious consequences. In some cases 
— subacute rheumatic fever — repeated 



exacerbations in the joint lesions and 
temperature occur before recovery 
finally is complete. Hyperpyrexia 
and suppurative pericarditis are com- 
plications entailing immediate danger, 
while endocarditis acts more slowly. 
In children the remote prognosis is 
always grave, death taking place in 
youth or early adult life. The gravid 
state also renders the condition more 
serious. One attack of rheumatic 
fever predisposes to others, and the 
ultimate prognosis becomes more 
somber in proportion with the per- 
sistence of recurrence. 

Twenty-three per cent, of acute 
articular rlieumatism patients go 
through one or more attacks without 
any clinical afifection of the heart, 
irrespective of the age when first at- 
tacked; 22 per cent, develop signs of 
carditis in the acute stage, these 
signs disappearing during the con- 
valescence; 18 to 20 per cent, of the 
cases which develop signs of endo- 
carditis, not clearing up before pa- 
tient leaves the hospital, have no 
permanent valvular lesion, the mur- 
murs being due to myocarditis, or in- 
competence from temporary hyper- 
emia of the valves, associated with 
dilatation. In 14.5 per cent, of cases 
with acute rheumatic endocarditis of 
severe type, one or more of the mur- 
murs disappear, such murmurs being 
due to associated dilatation. Cases 
in which the heart is going to recover 
completely show signs of such re- 
covery within twelve months of the 
acute attack, thoug'.i the process may 
not be completed till some years 
later. Kemp (Quarterly Jour, of 
Med., Apr., 1914). 

Analysis of 350 fatal cases of 
rheumatism. The patients comprised 
195 females, 155 males, 250 of them 
under the age of 12 years. Rheuma- 
tism is at its worst from the sixth to 
the twelfth year, and the majority of 
deaths occur before the twentieth 
year. The percentage of fatal first 



12 



RHEUMATISM (LEVISON AND -SAJOUS). 



attacks in childhood was nearly 23 
per cent. In the remaining 100 cases 
only 3 deaths were recorded in a 
first attack. Pericarditis was found 
in 215 of the 250 cases in childhood. 
One may expect to detect the friction 
sound in at least 80 per cent, of the 
cases of recent rheumatic pericar- 
ditis; it may be missed because the 
pericarditis is localized posteriorly, 
very limited in area, or evanescent. 
In the 250 fatal cases in childhood, 
the mitral valve was damaged in all 

^ but 3, the aortic in 102, the tricuspid 
in 78, the pulmonary in 6. Among 
100 cases in children, 82 died with 
evidence of acute carditis. Among 
100 older cases, only 9 died of acute 
carditis of the childhood type; 14 had 
recent endocarditis complicating for- 
mer valvular lesions; in 55 the valves 
were scarred by old disease, and 22 
died of malignant endocarditis. The 
usual time for malignant endocarditis 
is later childhood, adolescence, and 
early adult life. Death from myo- 
cardial failure without valvular lesion 
occurred in only 3 of the 350 cases. 
F. J. Poynton, C. D. S. Agassiz, and 

■J. Taylor (Pract, Oct., 1914). 

TREATMENT.— In the treatineiit 
of rheumatic fever it is of importance 
that the patient be placed in a large, 
well-ventilated room. He should be 
kept in bed, even where the affection 
is mild. A flannel nightgown should 
be worn, and the patient should sleep 
between blankets. The diet should 
be limited; during the febrile period 
liquid food should alone be given, 
with lemonade, carbonated waters, 
and milk as beverages. Regularity of 
the bowel movements should be 
maintained. 

Many authors deem it preferable 
to commence the treatment by in- 
stituting free purgation. 

As a specific remedy against the 
infection itself, salicylic acid and 
combinations containing this drug 
have nearly supplanted all others. 



Salicylic acid may either be given 
pure or in combination with the 
alkalies (sodium or strontium salicy- 
late). Pure salicylic acid is best tol- 
erated when given in capsules each 
containing 7j/2 to 15 grains (0.5 to 
1 Gm.) ; this dose is to be repeated 
fotir, five, or even six times per day, 
until the pain is relieved and the tem- 
perature falls. When symptoms of 
intoxication, viz., ringing in the ears, 
nausea, or occasionally, delirium ap- 
pear the use of the remedy must be 
discontinued for twelve to eighteen 
hours, or the dose greatly reduced. 
In many cases the pain is very 
rapidly subdued by this treatment 
and patients who, in the morning 
were not able to move, are completely 
relieved after a treatment of twelve 
hours. In other cases the fever sub- 
sides, but the pain and swelling of 
one or more joints continue for some 
time. Even when all symptoms have 
disappeared, it is advisable to con- 
tinue the use of salicylic acid for some 
time, btit in lesser dose. When the 
use of salicylic acid is discontinued 
too soon, recurrence is probable. 

Many authors prefer the use of 
sodium salicylate which is sometimes 
given in solution, 1 to 1^ drams (4 
to 6 Gm.) or even 2 drams (8 Gm.) 
being administered per diem. It has 
the same effect on the disease as the 
pure acid. By the third day the dose 
can generally be reduced to 15 grains 
(1 Gm.) every four or five hours. 
Other compounds which may be 
used are ammonium salicylate, salicin, 
and in particular, acetylsalicylic acid 
(aspirin) which, being nearly taste- 
less, is easily taken with sugar and 
water on a spoon or in milk, and is 
non-irritating to the stomach, pass- 
ing through it unaltered into the in- 



RHEUMATISM (LEVISON AND SAJOUS). 13 

testine where it is decomposed and passages to a healthy condition. 

absorbed in the form of salicylic acid. 1^"^^*^°^ ^"^ thorough cleansing of 

the nasal passages, combined with 
Inflammation of the throat empha- antiseptic treatment of the nose and 
sized as one of the earliest symptoms pharynx, should be a routine item of 
of rheumatism and a gargle of 20 antirheumatic treatment; and the 
Gni. (5 drams) of sodium salicylate operation of enucleation should be per- 
in 1000 Gm. (1 quart) of distilled formed without delay upon all rheu- 
water recommended. In the devel- ^^^-^^ children who exhibit chronic en- 
oped disease one should endeavor to largement of the tonsils or of the 
administer from 6 to 8 Gm. (VA to 2 tonsillar lymphatic glands. W. P. S. 
drams) in twenty-four hours to the Branson (Brit. Med. Jour., Nov. 23, 
adult; in children 1 Gm. (IS grains) 1912). 

per diem if the child is 2 years of j j -i • 

^ , , ^ r- /on • ^ -^ The writer recommends daily in- 

age or less, and 2 Gm. (30 grains) it . i * o r- /-ic ^.^ 

.*= ^ -, ', , . , 1, , jections of from 1 to 2 Gm. (15 to 

4 or 5. If the drug is not well borne ^ ... r i . xv,^ 

, , , ,1 ^1 30 grams) of sodium salicylate, ine 

in such large doses, these must be ^ '. r n 

, - . „ ^ /1T/ 1 1/ solution IS made as iollows: — 
decreased 5, 4, or 3 Gm. (1%, 1, or % 

drams) until tolerance is produced. Sodium salicylate 5.0 parts. 

It should not be given if nephritis Caffeine citrate 0.25 part. 

with the presence of casts in the urine Distilled ivater 25.0 parts. 

exists, but if the albuminuria is slight q^ ^^-^^^ f^^^^^ 5 ^^ 10 c.c. (1^ to 

and there are no casts it may be 2^/^ drams) are given daily. The 

given with caution. salicylate must be chemically pure 

When the myocardium shows signs ^^^ ^^^ solution kept in the dark, 

of being afifected, and the pulse irreg- j^ j^ ^^ special value where medica- 

ular, care must be taken not to ^.j^^^ ^^ mouth is not well borne, 

depress the heart further. If the p_ y_ Cgj-jiadas (Semana Medica, 

endocardium or pericardium are im- -p^^ 23^ 1915). 

plicated, the salicylate may be given, t-. ' •. a ^\, a • 

^ . , . , , , , The writer recommends the admin- 

but It must be withdrawn where there . - v ' 1 ^^ t 

. , ,. . , , . r istration of the salicylates by rectum 

IS delirium and other signs of cere- . 1 u *t . t 

T . or intravenously where the stomach 

bral excitement. In pregnancy it • 1 n- ^u 

.... is rebellious or the case requires 

must be given with caution. Aspirin • 1 .• -ri • 4. 

. , rr ■ 1 .1 1- r <. rapid action. The intravenous injec- 

is less efficacious than the salicylates, '^ r m * on • /ha ^-^ 

, , , , , . . ,.-,,, tions are of 10 to 20 grains (0.6 to 

and should be given in divided doses 1 o r- \ • oa <. 1 ..• a 

- 5' .,- .r • X 1.3 Gm.) in 20 per cent, solution and 

up to 1 to 3 Gm. (15 to 45 grains) . / Z ^- • * * 

^ , ,. ., given two or three times m twenty- 

focn '''rc:n°r"''^'7x/''^.''?r ^ fo"^ hours if necessary. Rectal in- 

(0.50 to 1.50 Gm.-7/. to 23 grains) ^^^.^^^ ^^^ ^r.i.rr.A, and as much 

also has its uses. If these remedies. or ,q \ k • 

r . , J • as 2 drams (8 c.c.) may be given, 

in succession do not produce im- •,, 1 c • • r^ \ : *4«^*,„... 

, . J with 15 minims (1 c.c.) of tincture 

provement, they can be combined . ^ a ■ ^ \ t,^„^c. 

^ . . , ' o J- 1- 1 .^ of opium, repeated in twelve hours, 

with advantage: Sodium sahcylate, n r \ ^ 4. 1 ^ ,„ 

^^^ ^ ,. ^ . . . . rtie r- The alkaline treatment may be com- 

025 Gm. (4 grains); aspmn, 015 Gm. ^.^^^ ^.^^^ ^^.^^ ^^^^ ^^^.^.^ .^ ^^_ ^^ 

i2}i grains); pyramidon. 0.15 Gm ^O- grain (0.6 to 1.3 Gm.) doses may 

(2y4 grains). In cases complicated ^^ ^.^^^^ ^^^^^ ^^^ ^^^^^ ^j^^^ p^j^^ 

with nephritis, cupping of the loins, .^ ^^^ .^.^^^^ j^^^ diminished. The 

milk diet, and laxatives are indicated. ^^^^ combination internally is am- 

Lemoine (Gaz. des pract., vol. xix, monium salicylate, 5 to 10 grains 

1912). (0.3 to 0.6 Gm.), with phenacetin, 1 

The commonest avenue of rheu- to 2 grains (0.06 to 0.13 Gni.), and 

matic infection is the tonsil, and next caffeine citrate, 1 grain (0.06 Gm.) 

to it the nose. The first essential of in capsules, every two hours. Bever- 

rational treatment of rheumatic in- ley Robinson (Med. Rec, Jan. 1, 

fection is restoration of the upper air 1916). 



14 



RHEUMATISM (LEVISON AND SAJOUS). 



The first essential is the thorugh 
searching out and removal of all foci 
of chronic infection and the prepara- 
tion of an autogenous vaccine from 
organisms isolated from such foci or 
from the urine if foci cannot be 
definitely located. The vaccines 
should be given in ascending doses, 
every week or ten days, adjusting the 
dose so as to secure a slight arthritic 
reaction. After improvement has ad- 
vanced, the intervals between doses 
may be lengthened. The treatment 
should be continued for a year or 
more. M. J. Rowlands (Lancet, Jan. 
15, 1916). 

Also serviceable where the simple 
salicylates are not well borne is salo- 
phen, which is gradually decomposed 
in the bowel into salicylic acid and 
acetylparamidophenol, and may be 
given in doses of 15 grains (1 Gm.) 
every three hours, preferably in con- 
junction with sodium bicarbonate, 10 
grains (0.6 Gm.) three times a day 
(W. H. Flint). This drug has also 
been recommended for use late in the 
course of the disease, when the acute 
fever has been mastered with salicylic 
acid. Oil of wintergreen may also be 
substituted for the other salicylates 
in doses of 20 minims (1.25 c.c), but 
is not unirritating to the stomach. 

Salicin. has a bitter taste, is much 
less nauseous than sodium salicylate, 
and can be conveniently given dis- 
solved in hot water. It only yields 43 
per cent, of its weight of salicylic 
acid, and hence the amount required 
is at least double that of sodium sali- 
cylate— 20 to 30 grains (1.3 to 2 Gm.) 
every hour or two hours until 1 ounce 
(30 Gm.) has been given, and then 
smaller doses according to the cir- 
cumstances. Acetylsalicylic acid is 
very active and has a marked anal- 
gesic effect. It cannot be prescribed 
with alkalies, which decompose it, 
and hence it is apt to bring on nausea 
and vomiting if given continuously. 
Methyl salicylate is also very apt to 



irritate the gastric mucous membrane, 
but in 10- to 20- minim (0.6 to 1.25 
c.c.) doses up to 60 or 90 minims 
(3.75 to 5.6 c.c.) per day, given in 
emulsion, or on sugar, or in milk, it 
acts powerfully, and externally ap- 
plied it is unrivalled for its analgesic 
action. Sodium benzoate has the 
same specific effect as the salicylate, 
but acts less powerfully. On the 
other hand, it is practically non- 
poisonous and has no disturbing side- 
effects. It can be given in 20-grain 
(1.3 Gm.) doses every two or three 
hours with satisfactory results in 
cases of uncomplicated rheumatic 
fever, but its practical usefulness is 
merely as a substitute for the more 
powerful salicylate, when the latter 
cannot be tolerated. Profuse per- 
spirations and skin eruptions are in- 
conveniences which frequently follow 
salicylates. They are also often 
deemed to act as heart depressants, 
but this is not borne out by exact 
observations. With large doses (250 
to 400 grains— 17 to 27 Gm.— per 
day), such as are sometimes given 
with the idea of thoroughly destroy- 
ing the infective germ, vomiting fre- 
quently occurs, and it is possible not 
only to seriously depress the nervous 
system, but to bring on a dangerous 
condition of acidosis. This can be 
prevented, to some extent at least, by 
giving about twice the amount of 
sodium bicarbonate with each dose 
of sodium salicylate, and taking care 
at the same time to avoid constipa- 
tion. But in an ordinary case of 
moderate severity 15 to 20 grains (1 
to 1.3 Gm.) of sodium salicylate every 
three or four hours form a sufficient 
dose. The joint pain and tempera- 
ture begin at once to be favorably 
affected, the former subsiding in from 
twelve to twenty-four hours, and the 
latter within forty-eight hours. The 
pulse and respiration fall with the 
temperature, and the joint effusion 
is absorbed in two or three days. 
The course of events usually resem- 
bles a crisis, though sometimes a 
lysis. If the temperature does not 
settle satisfactorily each dose may be 



RHEUMATISM (LEVISON AND SAJOUS). 



15 



increased, or one large additional 
dose of 40 to 60 grains (2.6 to 3 Gm.) 
may be given on one or on several 
daj's in succession. Additional ab- 
sorption of salicylic acid may be 
brought about by applying a dressing 
of methyl salicylate on lint to the 
affected joints. Where the rheumatic 
infection locates itself chiefly in the 
fibrous tissues, the condition generally 
in time yields to large doses of sali- 
cylates, along with free local applica- 
tion of methyl salicylate. When these 
rheumatic indurations are quite re- 
cent, potassium iodide and small blis- 
ters exert a marked deobstrucnt effect. 
Massage is even more effectual. 
Stockman (Pract., Jan., 1912). 

The writer nearly always used as- 
pirin and sodium salicylate jointly, 
administering as mucli as 10 or 15 
grains (0.6 to 1 Gm.) of sodium sali- 
cylate and 5 to 10 grains (0.3 to 0.6 
Gm.) of aspirin every two hours al- 
ternately. W. J. Judy (W. Va. Med. 
Jour., Aug., 1912). 

Sodium salicylate with sodium bi- 
carbonate, 1 part of the former with 
2 parts of the latter, is a most ef- 
fective antirheumatic, if the dose is 
gradually increased to a sufficient 
extent. If, when vomiting or tinnitus 
occurs, the medicine is suspended 
for a few hours, the unpleasant symp- 
toms will usually pass away, and the 
dose can later be raised to a consid- 
erably larger amount without causing 
their recurrence. In a rheumatic at- 
tack it is often desirable to increase 
the amount of salicylate to 150 or 200 
grains (10 to 13 Gm.) per day, with 
double the amount of sodium bicar- 
bonate, given in 10 doses. It is im- 
portant to prevent constipation, to 
keep the urine slightly alkaline and 
to stop the drug when vomiting or 
other symptoms due to salicylate 
occur. Lees (Brit. Med. Jour., Oct. 
12, 1912). 

The nodes call for intensification of 
the treatment. In 1 of 3 cases in 
children of 11 and 13, salicylates in- 
travenously and by the mouth were 
kept up for 7 montiis with slow im- 



provement and final recovery, even 
the heart functioning normally and 
the child increasing 22 pounds in 
weight. The nodes, though extremely 
numerous, persisted for 3 months. A 
girl of 11 years was given orally in 4 
months 130 Gm. (4% ounces) of the 
salicylate besides intravenous injec- 
tions up to a total of 9.5 Gm. (2% 
drams). Though the treatment was 
ordered discontinued, the parents 
continued it for 3 months longer (32 
injections by the vein) with a total of 
16 Gm. (4 drams), perfect recovery 
resulting. Navarro (Rev. de la Asoc. 
Med. Argentina, Apr.-June, 1920). 

Nothing certain is known of the 
manner in which saHcylic acid and its 
compounds influence the rheumatic 
infection. Possibly salicylic acid has 
a specific action on the micro-organ- 
isms ; it" is a reliable, but not an in- 
fallible, remedy, relieving the joint 
condition, shortening the disease, 
diminishing the likelihood of relapse, 
and probably protecting the heart. 
Some cases are rebellious to its 
action. Some patients do not toler- 
ate it, vomiting being induced. It 
may then be administered by inunc- 
tion or enema. For inimction a 20 
per cent, ointment of salicylic acid 
or of methyl salicylate may be used. 
For administration by enema Erlan- 
ger uses the following formula: — 

R Sodii salicylatis. 3iss to ij (6 to 8 Gm.). 
Tincturcc opii .. Tri.lxxv (5 c.c). 
Aqua f^iiiss (100 c.c). — M. 

This should be injected, after pre- 
liminary cleansing of the bowels, at 
body temperature, and should be re- 
tained as long as possible in the in- 
testines. 

Intrarectal administration of sodium 
salicylate recommended in refractory 
cases of acute and subacute rheumatism. 
The salicylate enema is given immedi- 
ately after a cleansing soapsuds en- 
ema, and is administered with a 



16 



RHEUMATISM (LEVISON AND SAJOUS). 



Davidson syringe and a rectal tube 
inserted 6 to 8 inches. First dose 
in men is usually 8 to 10 Gm. (2 
to IVi drams), in women 6 Gm. 
(1^2 drams), incorporated in 120 to 
180 c.c. (4 to 6 ounces) of plain or 
starrh water, with 1 to 1.5 <:.c. (16 to 
24 minims) of opium tincture. The 
dose may be repeated within 12 hours, 
but usually a daily enema suffices, with 
doses increasing from 30 to 50 per 
cent, daily until the limit of tolerance 
is reached. L. G. Heyn (Jour. Amer. 
Med. Assoc, Sept. 19, 1914). 

Where the effects of salicylates in 
acute rheumatism are not as expected, 
the so-called "alkaline treatment" may- 
be instituted, or, the two forms of 
treatment may be combined — a pro- 
cedure especially useful in children. 
This consists in the administration of 
20 or 30 grains (1.25 or 2 Gm.) of 
potassium bicarbonate, citrate, or 
acetate, or sodium bicarbonate every 
two or three hours for the first few 
days, or until the urine is alkaline. 
Luff advises combined salicylic and 
alkaline medication in all cases of rheu- 
matic fever. He gives 20 grains (1.25 
Gm.) of sodium salicylate and 30 
grains (2 Gm.) of potassium bicarbo- 
nate every two hours until pain is re- 
lieved, then every four hours till the 
temperature has fallen to normal. Fif- 
teen grains (1 Gm.) of the salicylate 
and 20 grains (1.25 Gm.) of the bicar- 
bonate are then given every four hours 
until all joint symptoms have disap- 
peared, and after this three or four 
times a day for a fortnight longer. 

Comparative statistics show that pa- 
tients do not recover any more quickly 
under salicylates than with the alk- 
aline treatment, but with the salicylate 
treatment pain is sooner relieved. 
Heart complications are not any more 
common when treating with the salicy- 
lates. J. L. Miller (New York Med. 
Jour., July 4, 1914). 



Intravenous and subcutaneous injec- 
tions of salicylates have been recom- 
mended by several observers, both to 
avoid upsetting the stomach and for 
prompt, powerful effect. Behr lauds 
the following combination for intra- 
venous use, originated by Mendel : — 

IJ Sod'n salicylatis ... 3ij (8 Gm.). 
Caffeince sodiosal- 

icylatis (N. F.) . . 5ss (2 Gm.). 
Aqiice stcril(c, q.s. ad f5iss (50 c.c). — S. 

Methyl salicylate, or artificial oil 
of wintergreen, is recommended for ex- 
ternal use in rheumatic fever. It is a 
volatile fluid of an aromatic odor. The 
affected joints are to be painted with 
the drug and enveloped with some im- 
pervious material. Experience has 
shown that the salicylic acid contained 
in methyl salicylate is absorbed through 
the skin. It is also chemically demon- 
strable in the urine. It removes the 
pain and reduces the temperature. 

In acute rheumatism and allied con- 
ditions such as acute rheumatic sci- 
atica, the result of thyroid treatment 
may be striking. Tompkins (So. Med. 
Jour., Dec, 1910). 

Hypodermic injection of salicylates 
advocated, for the purpose of secur- 
ing prompt action and avoiding di- 
gestive disturbances and toxic symp- 
toms. In acute rheumatic infection 
of joints, heart, pericardium, pleura, 
and central nervous system (chorea), 
inject 10 c.c. (2^/2 drams) of 20 per 
cent, sterile solution of fresh sodium 
salicylate per 100 pounds of body 
weight. First disinfect a spot out- 
side of the median line of the thigh 
with fresh iodine tincture. Through 
this inject sterile cocaine solution (^ 
grain — 0.008 Gm. — in 30 drops) under 
the skin, and after waiting fully fif- 
teen minutes inject salicylate solu- 
tion under the same spot. This causes 
general improvement within three 
hours. Repeat the injection every 
twelve hours. In severe cases, with 
many seats of involvement, increase 



RHEUMATISM (LEVISON AND SAJOUS). 



17 



the dose to 15 c.c. (^ ounce) per 100 
pounds weight. In chronic cases, in- 
ject every twenty-four hours 10 c.c. 
(2^ drams) per 100 pounds of the 
following: Salicylic acid, 10 Gm. (2^ 
drams); sesame oil, 80 Gm. (2% 
ounces); pure alcohol, 5 Gm. (75 
drams); gum camphor, 5 Gm. (75 
grains). This is to be sterilized 
before adding the alcohol, and after- 
ward excluded from contact with 
air, to avoid evaporation of alcohol. 
The effect of the injection in chronic 
cases is obtained more rapidly when 
multiple localizations of the rheu- 
matic process are present than when 
one joint is affected. In the former, 
pain and stiffness usually improve 
after the first injection; in the latter, 
after the third. The addition of 
camphor (from 5 to 20 per cent.) was 
found beneficial in stimulating the 
heart when the pericardium or the 
endocardium was involved. Seibert 
(Med. Rec, Mar. 11, 1911). 

Magnesium sulphate, administered 
by intramuscular injection, by mouth, 
and applied externally, found val- 
uable in cases of acute articular 
rheumatism. Intramuscular injec- 
tions of 4 c.c. (1 dram) of a sterilized 
25 per cent, solution of the salt, all 
aseptic precautions being observed, 
brought rapid relief from pain, re- 
duced stiffness and swelling, and 
sometimes considerably lowered tem- 
perature. No pain followed the 
injections. In some instances purga- 
tion resulted. Injections were re- 
peated on succeeding or alternate 
days. A saturated solution was ap- 
plied to the inflamed joints with 
benefit. The intramuscular injections 
are recommended for cases in which 
salicylates fail to give results. A. B. 
Jackson (N. Y. Med. Jour., June 24, 
1911). 

In many cases where the salicylates 
failed in their action, or were not 
well borne, coUargol in the form of 
an intravenous injection, 2 c.c. (32 
minims) of a 5 per cent, solution, or 
an enema of 50 c.c. (1% ounces) of 
a 5 per cent, solution, gave excellent 
results. In giving the intravenous in- 



jection the heart must be normal, as 
there is a sudden rise of temperature 
to 40° C. (104° F.); the injection per 
rectum is not followed by this rise in 
temperature, and the results are about 
the same. Junghaus (Deut. med. 
Woch., Nov. 1, 1912). 

Case of rheumatic fever in which, 
although sodium salicylate appeared 
at first to be giving excellent results, 
the pain, joint swelling, and fever 
later returned, the heart rate in- 
creased, and the first sound became 
muffled. Ten days' energetic treat- 
ment with the salicylate proving com- 
pletely ineffectual, 8 Gm. (2 drams) 
of antipyrin were administered in 
two days, and the salicylate in daily 
doses of 5 Gm. (75 grains) resumed 
immediately after. The fever was 
thus rapidly overcome and convales- 
cence entered upon. The return to 
a massive dose of the salicylate after 
the two days' intermission seemed the 
essential factor in the benefit ob- 
tained. Interrupted administration of 
salicylates has already been recom- 
mended for obstinate cases, and anti- 
pyrin seems especially suitable for 
use during the intervals. Roch (Rev. 
med. de la Suisse romande, Feb., 
1913). 

The writer's experience with the 
intravenous administration of sodium 
salicylate comprises 12 cases of artic- 
ular rheumatism of various degrees 
of severity, in which about 130 injec- 
tions were used. The two most im- 
portant points to be observed in the 
giving of the injections were found 
to be: (1) to use only a very fine, 
sharp needle, so that the trauma to 
the vein wall may be as slight as pos- 
sible; and (2) to have the solution 
fresh and made with chemically pure, 
crystalline sodium salicylate. The 
stock solution was made by dissolving 
10 Gm. (214 drams) of C. P. crystal- 
line sodium salicylate in 50 c.c. (1% 
ounces) of distilled water, freshly 
sterilized by boiling. The drug was 
weighed and handled as aseptically as 
possible and the solution, after being 
made, not subjected to further sterili- 
zation. The solution should be per- 



8—2 



18 



RHEUMATISM (LEVISON AND SAJOUS). 



fectly colorless and, if protected from 
the light, was found to keep for 
several days. L. A. Conner (Med. 
Rec, Feb. 21, 1914). 

Attention to the joints in rheu- 
matic fever is of great importance. 
They should be placed at complete 
rest by means of splints, and may 
also with advantage be wrapped in 
cotton or in cloths wet with a satu- 
rated solution of magnesium sul- 
phate or with lead water and lauda- 
num. Methyl salicylate, as already 
mentioned, may also be applied. 

Bourget recommends the following 

ointment : — 

^ Acidi salicylici gr. xlv (3 Gm.). 

Olei tcrebinthince ... mxlv (3 c.c). 

Adipis lance hydrosi, 

Adipis bcnzoinati. .3.3. 5v (20 Gm.). 

Fiant unguentum. 

Sig.: To be applied, and covered with 
absorbent cotton and an impervious ma- 
terial. 

Baker finds the following collodion 
useful in relieving pain : — 

I^ Phenylis salicylatis 3j (4 Gm.). 

Mthcris f5i (4 c.c.) . 

Collodii ill (30 c.c). 

M. Sig.: To be painted on the affected 
joints twice daily or oftener. 

Arendt praises a formula contain- 
ing ichthyol : — 

R Ichthyolis 3iiss (10 Gm.). 

Alcoliolis dilttti fSiiss (10 c.c). 

Aqu<u destillatcc f3x (40 c.c). — M. 

Robinson has found the following 
ointment so efficient as to permit of 
dispensing with internal treatment 
altogether : — 

B Mentholis 3j (4 Gm.) . 

Methylis salicylatis .... f3j (4 c.c). 

Acidi salicylici 3ij (8 Gm.). 

Alcoholis q. s. ad fjj (30 c.c). 

M. Sig.: Paint jomts briskly with 
camel's-hair brush, cover with absorbent 
cotton and oiled silk, and bandage snugly 
but not tightly. 



When the epidermis begins to peel 
an emollient ointment should be sub- 
stituted for a day or two. 

Sixteen cases of acute rheumatism 
treated l)y typhoid vaccine, used only 
as a standardized foreign protein. 
Sixteen minims (1 c.c.) were given in- 
travenously daily until a cure had 
been obtained. The treatment is 
justifiable where apical abscesses, in- 
fected tonsils, gall-bladder, appendix, 
or genitourinary tract can be demon- 
strated and removed, and in those re- 
fractory to other treatment. Lyter 
(Jour. Amer. Med. Assoc, Jan. 5, 1918). 
Excellent results from hypodermic 
injections, once daily, of 150 c.c. 
(5 ounces) of a solution of 7 Gm. 
(108 grains) of sodium chloride and 
10 Gm. (155 grains) of sodium sul- 
phate in a liter (18 ounces) of water. 
It is seldom necessary to give more 
than 3 or 4 doses to obtain marked 
improvement. S. L. Brian (La Sem- 
ana Med., June 6, 1918). 

Subcutaneous injection of oxygen 
systematically used in thousands of 
patients with rheumatism, mostly 
subacute and chronic. It is a power- 
ful adjuvant to other measures. The 
writer usually injects 100 c.c. (3% 
ounces) at the site of the pain, some- 
times injecting all the larger joints at 
1 sitting, using up 2, 4, or more liters. 
An elderly woman with chronic nodu- 
lar rheumatism for two years in hands 
and knees was relieved of all pain 
and inflammation by 8 injections. 
The oxygen was injected into the 
dorsum of the hands and massaged 
into the fingers. Zabaleta (Siglo med- 
ico, Aug. 10, 1918). 

In subacute and chronic rheuma- 
tism several writers advise the use of 
a Z2) per cent, ichthyol ointment or a 
20 per cent, ichthyol-glycerin solu- 
tion, aided by ichthyol and iodides in- 
ternally. Salicylic cataphoresis has 

also 1)een used. 

Report of rapid cure of acute rheu- 
matism after intra-articular injections 
of sodium, salicylate by the catapho- 
retic method. Similar cases reported. 



RHEUMATISM (LEVISON AND SAJOUS). 



19 



Wullyamoz (Brit. Med. Jour., Aug. 
13, 1910). 

Occasionally cases of rheumatism 
are met with in which the pains do 
not yield to sodium salicylate and yet 
promptly yield to acetylsalicylic acid 
(aspirin). Internal administration of 
salicylates frequently fails to give re- 
lief to the pain experienced about the 
fibrous tissues, notably under the 
heels in patients who have had a pre- 
vious attack of acute articular rheu- 
matism. In such cases the local use 
of oil of wintergreen, 1 dram (4 Gm.) 
to an once (30 Gm.) of lanolin, will 
generally give relief. The same ap- 
plies to the pain accompanying acute 
rheumatic pleurisy or pericarditis. 
For painful conditions about fibrous 
structures the addition of from 3 to 
5 grains (0.2 to 0.3 Gm.) of potassium 
iodide to the sodium salicylate often 
proves beneficial. Joint effusions of 
rheumatism are responsive to salicy- 
lates in proportion to the absence of 
mechanical irritation by movement. 
In erythema nodosum local treatment 
with oil of wintergreen brings marked 
relief of the pain and probably a 
shortened duration of the attack. A. 
F. Voelcker (Clin. Jour., Aug. 16, 
1911). 

The writer recommends in the 
treatment of light attacks of rheuma- 
tism, as well as in sciatica, gout, and 
neuralgias in general, the following: — 

Acidi salicylici 10 Gm. (2^ dr.). 

Olei terehinthin.(c ... SO Cc. (1% oz.). 
Sulphuris pnecipitati. 40 Gm. (l^/^ oz.). 

M. ft. lotio. 

The salicylic acid is dissolved in 10 
Gm. (2^ drams) of the turpentine, 
the sulphur mixed with the remainder, 
and the two portions then mixed. 
After the preparation has been ap- 
plied to the skin, it is covered with a 
layer of impermeable tissue held by 
a bandage. When the dressing has 
been allowed to remain for three or 
four days the skin, on its removal, 
will be found to have become de- 
tached from the deeper layers. Un- 
less the patient is sensitive, the 
preparation may be applied again. 



Otherwise, it is well to use a zinc 
paste. Scharff (Therap. Monats., 
Feb., 1912). 

Excellent results obtained by apply- 
ing externally a mixture of 2 parts 
of ground camphor and 1 part of 
phenol, adding 5 per cent, alcohol to 
the mixture. The result is an oily 
fluid, sparingly soluble in water, and 
free from caustic action. Only very 
delicate skins feel a slight smarting. 
It seems to be especially toxic to 
streptococci. V. Chlumsky (Zent- 
ralbl. f. inn. Med., Mar. 9, 1912). 

In children the salicylates, also 
hold first place. The dose must l>e 
90 to 150 grains (5.8 to 9.7 Gm.) in 
divided doses at short intervals dur- 
ing the first 24 hours, with a nearly 
equal amount of sodium bicarbonate. 
Later the dose may be lessened. If 
the case responds at all the fever 
and pain subsides in 48 hours. In 
some cases morphine must be given. 
The joints may b-e wrapped in ■ cot- 
ton or local applications of lead water 
and laudanum, magnesium sulphate 
or oil of gaultheria made. A splint 
may be applied. Abundance of water, 
lemonade and orangeade should be 
given. The food should be in the 
form of milk or milk products, 
cereals and broths. Rarely, a stock 
vaccine has proved beneficial. Dis- 
eased tonsils should be removed. 
Riesman (Trans. Phila. Co. Med. Soc; 
Med. Rec, Apr. 16, 1921). 

Where the joint pain remains 
severe in spite of salicylates, Dover's 
powder may be ^8:iven ; or, particu- 
larly at nig^ht, an injection of mor- 
phine may become necessary. 

The complications of acute articu- 
lar rheumatism should be treated ac- 
cording to the nature and the indi- 
cations of each. Hyperpyrexia and 
cerebral rheuinatism may necessitate 
the application of tepid and even 
cold baths combined with large doses 
of antipyretics; the cold baths or cold 
pack should be begun as soon as the 



20 



RHEUMATISM (LEVISON AND SAJOUS). 



temperature starts to rise quickly 
above 105° F. (40.5° C), otherwise 
considerable danger to life may be 
entailed. Upon the advent of endo- 
carditis the use of the ice-bag or pre- 
cordial blistering should be availed 
of, and digitalis may have to be em- 
ployed. 

A persistently high pulse rate in 
acute articular rheumatism is always 
to be regarded as indicative of myo- 
cardial involvement, and as long as 
it continues absolute rest is essential. 
Rest in bed should be persisted in as 
long as six months to a year if the 
physical signs indicate that the heart 
has not recovered completely. Dur- 
ing the acute stages of the disease 
the pain may make the patient very 
restless. Under these circumstances 
an ice-bag may be applied over the 
heart, and sleep should be obtained 
by the use of morphine, since the 
other hypnotics do not sufficiently re- 
lieve pain to permit rest. If the 
patient has not much pain, but is 
nevertheless restless, the bromides 
are of no value. When the heart re- 
mains persistently weak, and suffi- 
cient time has elapsed for inflamma- 
tory processes to quiet down, minute 
doses of digitalis and arsenic, contin- 
ued over a long period, are often of 
value. Turnbull (Austral. Med. Jour.; 
Therap. Gaz., Nov. 15, 1911). 

When the fever declines, but one 
or more articulations remain swollen 
and painful, it has been recommended 
to employ bandaging for some time. 
Also, baths in hot water or, better, 
hot-air baths, will in many cases 
bring relief. Massage is likewise a 
valuable measure. 

Iron is usually a useful remedy 
during convalescence, in view of the 
rapid anemia induced by the disease. 
With it may be coupled quinine and 
strychnine. Arsenic may also be of 
value. A generous diet should be 
allowed. 



In rheumatic conditions associated 
with anemia and in sore throat of 
rheumatic origin, following mixture 
recommended: Dissolve 1 dram (4 
Gm.) of sodium saUcylate in 2 ounces 
(60 c.c.) of water. Add liquor ferri 
perchloridi, plus an ounce of water, 
giving dark-purple mixture. Then 
add 1 dram of potassium bicarbonate 
dissolved in 1 ounce (30 c.c.) of water, 
and fill up bottle to 8 ounces with 
water. Drinkwater (Liverpool Med- 
ico-Chir. Jour., July, 1911). 

No treatment has been found able to 
prevent surely the complications or re- 
currence, but most authors agree that 
the use of salicylates in sufficient doses 
continued for some time after the re- 
turn of normal temperature gives the 
best results in both respects. 

Cases showing the possibility of 
treatment with colloidal sulphur, of 
cutting short an oncoming chronic 
rheumatic state following attacks of 
acute rheumatism. The patient was 
completely relieved, resuming his oc- 
cupation in three months, in spite of 
several interruptions in the treatment. 
The solution of colloidal sulphur em- 
ployed contained 0.2 Gm. (3 grains) 
of sulphur to every 15 c.c. (^ ounce), 
and was given in doses of 1 teaspoon- 
ful before breakfast and supper, grad- 
ually increased to 1 tablespoonful. 
The solution was rendered palatable 
with sugar and an 'aromatic prepara- 
tion. Sodium salicylate, having no 
efifect on the pain or in preventing 
recurrence of subacute attacks, may 
be advantageously replaced by qui- 
nine sulphate in the dose of 5 grains 
(0.3 Gm.) twice a day. A. Robin and 
L. C. Maillard (Bull, de I'Acad. de 
Med., Nov. 25, 1913). 

The writer regards all arthritic in- 
flammation as microbic, and 90 per 
cent, of the cases are due to strepto- 
cocci. Acute inflammatory rheuma- 
tism, chronic , articular rheumatism, 
and arthritis deformans are but dif- 
ferent manifestations of one cause, 
modified by individual susceptibility, 
both constitutional and local, and 



RHEUMATISM (LEVISON AND SAJOUS). 



21 



duration of disease. He reports suc- 
cessful treatment of chronic rheuma- 
tism by means of autogenous vac- 
cines. The preferable source for 
these is the pharynx. The benefit 
from vaccine ranged from total cure 
in the mild cases, to disappearance 
of all symptoms except transitory 
slight stiffness in the most severe. 
Greeley (Med. Rec, June 13, 1914). 

Where a case persists over many 
weeks, a focus of infection in the ton- 
sils, nasal sinuses, ears, or elsewhere in 
the body should be sought. Tonsillec- 
tomy may be required. 

The writer deprecates the general 
tendency to refrain from operating on 
inflamed tonsils associated with acute 
joint involvement. There may be 
greater danger in deferring operation 
too long. If the tonsils are the source 
of infection, their continued presence 
increases the danger of secondary in- 
volvement of the heart. Tonsillec- 
tomy is indicated as soon as the acute 
tonsillar inflammation sul)sides. Sali- 
cylates in large doses should be used 
to allay joint pains before operating. 
With intensive salicylic treatment 
the writer also gives sterile milk sub- 
cutaneously, thus producing hyper- 
emia of and exudation over the in- 
volved structures. The rheumatic 
process is controlled in a few days. 
Of 70 cases treated, none developed 
pericarditis, and but 2 a cardiac lesion. 
The treatment succeeds where sali- 
cylate treatment alone seems ineffec- 
tive. Endocarditis is favorably influ- 
enced by intramuscular injections of 
10 c.c. (2;/ drams) of sterile milk. 
A. Edelmann (Miinch. med. Woch., 
Dec. 18, 1917). 

Nephritis plays the chief role in 
causing senile rheumatism. If the 
patient is robust the writer gives 
Seidlitz mixture or magnesium citrate 
before breakfast; if frail, a compound 
cathartic pill at bedtime. Cabinet 
baths once or twice a week are very 
beneficial. Salicylates irritate the 
kidneys. Heroine usually relieves 
the pain in acute cases. Superheated 
air at 130°, 180°, or 200° C. is applied 



to cases with a tendency to defor- 
mity. Sodium succinate, 10 grains 
(0.6 Gm.) every three hours, is often 
of great value. Senile rheumatism 
improves on exercise. M. W. Thewlis 
(Med. Rev. of Reviews, June, 1918). 

MUSCULAR RHEUMATISM. 

Muscular rheumatism, or myalgia, is 
an affection of the muscles and the re- 
lated fasciae, causing pain and stiffness, 
which usually disappear after some 
days. It sometimes assumes chronicity, 
being then accompanied by the forma- 
tion of fibrous bands and nodules in 
the muscles. 

SYMPTOMS.— The principal symp- 
tom is pain, which may be spontaneous 
or caused by movements or pressure of 
the diseased parts. The pain in some 
cases remains limited to the muscles 
first affected, but sometimes it suddenly 
disappears from these and attacks an- 
other group of muscles. Slight fever 
sometimes attends the affection. The 
symptoms vary according to the 
muscles affected. In rheumatism ot 
the intercostal muscles — pleurodynia — 
(sometimes with involvement of the 
pectorals or the serratus magnus), 
breathing is painful and the disease 
may be confounded with pleurisy. 
Localized tenderness may exist over 
the involved muscles. When the mus- 
cles of the abdominal wall are affected, 
there is excessive tenderness to pressure, 
and the symptoms may resemble those 
of acute peritonitis ; but the absence of 
fever is of great value as a diagnostic 
sign. Rheumatism of the muscles of 
the back occasionally gives rise to opis- 
thotonos, and suspicion of spinal men- 
ingitis may arise. Lumbago, or in- 
volvement of the lumbar muscles, may 
completely incapacitate the patient, and 
may simulate disease of the sacroiliac 
joint, vertebrae, etc. Rheumatism of 



22 



RHEUMATISM (LEVISON AND SAJOUS). 



the muscles of the neck causes stiffness, 
and, when the muscles of one side only 
are affected, rheumatic torticollis (wry- 
neck) is produced. The sternomastoid 
muscle may become prominent as a 
tense, tender cord, and rotates the head 
toward the involved side. 

Pleurodynia can be distinguished 
from pleuritis by the absence of a fric- 
tion rub, and from intercostal neuralgia 
by the absence of the characteristic 
tender or painful spots, and by the fact 
that the pain does not strictly follow 
the course of the intercostal nerves. 

The acute form of muscular rheuma- 
tism passes away in a few days. The 
chronic form may continue for weeks 
and months and often provokes forma- 
tion of new connective tissue, with its 
consequences — stiffening of the muscles 
and contractures. Sometimes small 
fibrous bands and nodules are formed 
in the muscles and give rise to much 
pain and tenderness. 

Rheumatism of the muscles is in 
some cases complicated Avith myositis, 
which may be general or localized, — 
limited, for instance, to the muscle of 
the heart. 

Muscular rheumatism is a danger- 
ous diagnosis for a conscientious 
physician to make. The correct diag- 
nosis may be either aortic aneurism, 
cancer of the pleura, tabes, osteomye- 
litis, spondylitis deformans, bone tu- 
berculosis, syphilitic periostitis, lead 
poisoning, morphine habit, alcoholic 
neuritis, trichinosis, gonorrheal sep- 
sis, onset of an acute infection 
(typhoid, influenza, variola, arterior 
poliomyelitis, meningitis), intestinal 
autointoxication, sacroiliac joint re- 
laxation, local disease of muscle, 
hematoma due to trauma, hematoma 
following vascular change (as in ty- 
phoid, sepsis, jaundice), muscular 
cicatrices following fibrous myositis, 
atheroma of arteries in muscle (as in 
intermittent claudication), muscle ab- 



scess, infarct, gumma, echinococcus 
cyst, or new growth. The diagnosis 
of muscular rheumatism must be 
made by exclusion. M. A. Rabinowitz 
(N. Y. Med. Jour., July 12, 1913). 

ETIOLOGY AND PATHOLOGY. 

— Overwork, especially when combined 
with exposure to cold and dampness, 
has always been considered as the com- 
mon cause of rheumatism of the mus- 
cles. Many persons are very sensitive 
to draughts, and readily develop the 
affection, especially upon sudden cool- 
ing after physical motion sufficient to 
cause perspiration. The disease com- 
monly occurs after the thirtieth year, 
but is also observed before tliat aee. 
The disease is very liable to recur in 
muscles which once have been affected 
by it; especially in the muscles of the 
neck. 

In all probability the muscular form 
of rheumatism, like the articular form, 
is caused by micro-organisms, but their 
presence in the affected muscles 
has as yet not been proved by direct 
observation. 

The pathological condition pro- 
duced is believed to be chiefiy an in- 
flammation of the fibrous investment 
of the muscle fibers, the attachments 
of the muscles to periosteum, and the 
fasciae surrounding them. Stress is laid 
by some on disturbance of the sensory 
nerve endings in the muscles. 

J. Madison Taylor states that fibro- 
myositis is often a common factor in 
many states variously named where 
either pain, tenderness, or lameness is 
a feature. It may not be painful, 
merely a latent tenderness. It is 
often superadded to other causes of 
disability, complicating and obscuring 
them; is only to be differentiated by 
expert tactile exploration ; the condition 
should be remedied to permit exact 



RHEUMATISM (LEVISON AND SAJOUS). 



22> 



diagnosis. The site can usually be 
located and evaluated by alterations 
in the local density, tension, mobility 
or restriction of motion. Nodes are 
often minute but characteristic. 

Nearly always diagnostic light is 
afforded by definite tenderness and 
morphological alteration in paraverte- 
bral structures corresponding to the 
origin of the sympathetic innervation 
at the site of the subsidiary centers in 
the spinal cord. 

TREATMENT.— For internal use 
salicylic acid and its compounds are 
much employed and will sometimes, 
though not in all cases, bring relief. 
When the salicylates fail to effect a 
cure, tincture of colchicum, potas- 
sium iodide, or mercury may be. tried 
together with an antigout diet. 

Thiosinamine at times checks prog- 
ress of chronic rheumatism. Daily 
dosage of 0.06 to 0.1 Gm. (1 to 1^ 
grains) by injection or ingestion can 
be safely employed. Renon (Bull, de 
I'Acad. de Med., Apr. 25, 1911). 

The following treatment of muscu- 
lar rheumatism recommended: (1) 
rest in bed; (2) liberal diet of milk, 
eggs, light meats, farinaceous articles 
and cruciferous vegetables. Butter- 
milk and water between meals ad lib- 
itum; (3) general bath daily, with 
temperature progressively increased, 
followed by a blanket or alcohol 
sweat; (4) massage, after pain and 
tenderness under control at least 
twenty-four hours; (5) in lumbago or 
other localized muscular troubles 
where general methods inefficient: 
acupuncture or injection directly into 
involved muscle of 10 c.c. (2j/2 drams) 
of ice-cold normal salt solution; (6) 
where severe pain: salicylates, at 
first in large hourly doses, with 
sodium bicarbonate. Locally, 20 per 
cent salicylic acid ointment or lini- 
ment of oil of gaultheria, followed by 
flannel jacket or bandages, with hot- 
water bottles or electric pads. Meyer 
(N. Y. Med. Jour., July 5, 1913). 



Externally, tincture of iodine and 
all the rubefacients — ammonia, cam- 
phor, turpentine, etc. — are to be tried ; 
also warmth in the form of hot water, 
poultices, and hot baths (Russian or 
Turkish). Hot-air baths have been 
much recommended. The external 
use of methyl salicylate often alle- 
viates the pain. Belladonna plaster, 
chloroform liniment, and the galvanic 
current may also be used for this pur- 
pose. Massage may completely cure 
a recent case. Rest of the affected 
muscles should be procured by all 
means possible. In pleurodynia 
strapping the side with adhesive 
plaster generally affords marked re- 
lief. In lumbago as well as in pleu- 
rodynia light application of the 
Paquelin cautery is frequently of 
marked value. Otto has recom- 
mended a single injection of 7^ to 
15 grains (0.5 to 1 Gm.) of freshly 
obtained sodium iodate in 5 per cent, 
solution at the site of pain. Sajous 
injects normal saline solution sub- 
cutaneously — 2 fluidounces (60 c.c.) 
■ — daily and gives, besides sodium 
salicylate and sodium carbonate (not 
bicarbonate) in full doses, watching 
the heart carefully. 

Injection of 5 or 10 c.c. (80 to 160 
minims) of salt solution into the 
muscle at the most painful point will 
frequently relieve the pain, though, of 
course, it has no effect upon the 
cause. Schmidt (Med. Klinik, vi, 
131, 1910). 

The chief measure, other than rest 
in bed, in the treatment of muscular 
rheumatism is the application of heat 
in the form of fomentations, poultices, 
and hot-water bags. Dry cupping 
over the tender region one-half hour 
twice or thrice daily is very beneficial. 
One or two electric-light bulbs placed 
six inches from the affected part, a 
piece of asbestos, tin or woolen ma- 
terial encircling, so as to concentrate 



24 RHEUMATISM (LEVISON AND SAJOUS). 

the heat, will produce a useful hyper- den and severe strain on tendons and 

emia; the skin should be protected by ligaments; (4) absorption of irritating 

anointing with petrolatum. The elec- toxins from the alimentary tract; (5) 

trie-light baking apparatus is, how- tonsillitis and pharyngitis; (6) influ- 

ever, more serviceable. This treat- enza; (7) febricula. The forms most 

ment the author has found verj' bene- commonly seen are: (1) muscular 

ficial, together with light massage, rheumatism, involving especially the 

after which a woolen cloth is placed muscles of the neck, those of the 

over the hypercmic area. He has also shoulder and upper arm (brachial 

found serviceable light massage with fil)rositis), the intercostal muscles, or 

the use of an analgesic lubricant: — the lumbar muscles (lumbago); (2) 

B MenthoVis Dupuytren's contraction; (3) fibrositis 

Camphom.Az ?i-ij (4 to 8 Gm.). of the plantar fascia; (4) pads upon 

Chlorali hx- finger-joints, usually confined to the 

drati 3ss-j (2 to 4 Gm.). dorsal aspects of the proximal inter- 

Olei gaultlie- phalangeal joints, and apparently un- 

■yi^cc 5ii-iv (8 to 15 Gm.). related to rheumatoid arthritis, or 

Adipis lance h\<- gout. In chronic villous synovitis, 

drosi ...... Bi-ij (30 to 60 Gm.). though strictly not a form of fibro- 

M, r, . sitis, the correct treatment is simi- 

. et ft. unguentum. , ' , ^ , 

lar to that of the other conditions 

After the patient is able to be out mentioned. It is purely local, usually 

of bed a suitable adhesive plaster occurs in the knee, and characterized 

dressing will allow him to walk, with ^^y crepitus or creaking on movement, 

slight muscular fixation. J. H. Shaw ^^^ by p^j^ ^nd tenderness on use. 

(N. Y. Med. Jour., July 5, 1913). j^ j^e treatment of an acute fibro- 

When the disease has passed over sitis, a saline aperient should always 

to the chronic sta-e further use of be given at the onset of the attack. 

, - \ . . , r • 1 snd repeated as necessary. Saucy- 

massage and electricity is beneficial. j^^^^ ^^^ ^^ jj^^j^ ^^^^^^.^^^ ^,^1^^^ 

Iodine ointment may be used with though aspirin is of decided use for 

benefit. In cases attended by indura- the relief of pain in severe cases, 

tion and fibrous nodules in the mus- Potassium iodide should always, if 

cles, characterized often by contin- possible, be given in full doses of 10 

, . ... or 12 grams (0.6 or 0.// Gm.), com- 

uous and very intense pain, excision i • ^ vu ^ • i „„^ „«r^,v, 

-^ . bined with tonics such as nux vomica 

of the hard nodules of fibrous tissue or the compound glycerophosphate 
often gives immediate relief. syrup. If symptoms of iodism result, 
Chronic fibrositis is generally la- iodipin may be tried. Fibrolysin was 
belled "rheumatic," but undoubtedly employed in several cases of thicken- 
not a sequel of acute rheumatism, and "^S and contraction of fibrous tissues 
in no sense connected with it; the es- i" different forms of fibrositis and 
sential pathological change is, in arthritis, as well as in several cases 
general, an inflammatory hyperplasia o^ Dupuytren's contraction, with good 
of the white fibrous tissue in various results in about two-thirds ot the 
parts of the body. Such aflfections cases. It should be injected under 
cause pain and stiffness, the former strict antiseptic precautions into the 
aggravated by any sudden movement. ^eep subcutaneous tissues of the 
Recurrence is common and if not suit- "PP^^" a™' ^ach <.rm being injected 
ably treated, the thickened fibrous alternately. It is necessary to give 
tissue remains as indurations in 30 to 40 injections in all, and they 
various' situations. The commonest should be administered on alternate 
causes of local fibrositis are: (1) cold, days. After 20 injections have been 
damp, and wet; (2) extremes of heat ' given movements and massage of the 
and cold; (3) local injuries, as by sud- affected fibrous tissues should be 



RHEUMATISM (LEVISON AND SAJOUS). 



25 



commenced. In the treatment of pads 
upon the finger-joints the only pro- 
cedure found useful besides fibroly- 
sin was the nightly inunction of a 25 
per cent, iothion ointment. In the 
early stages of an acute fibrositis hot 
fomentations are useful. Afterward 
one of the best external applications 
is a mixture of equal parts of chloral 
hydrate, camphor, and menthol. The 
resulting liquid should be painted over 
the painful area, and then gently rub- 
bed in with the fingers. Another use- 
ful procedure is to paint the painful 
area with tincture of iodine and then 
apply a hot linseed poultice or very 
hot fomentation. In the latter stages 
the aconite, belladonna, and chloro- 
form liniment applied on lint is fre- 
quently most beneficial. In a very 
localized fibrositis counterirritation, 
especially by the thermocautery, is 
sometimes of great use. Rest of the 
affected parts and diaphoresis are two 
of the most important procedures in 
the treatment, the latter being es- 
pecially beneficial at the onset of the 
attack. Heat is of great value, and 
if employed early will frequently 
abort an attack. If it is to be applied 
to the whole body the electric-light 
cabinet is most convenient and val- 
uable. In lumbago and chronic vil- 
lous synovitis of the knees, the most 
eflfective local treatment is super- 
heated air, applied for fifteen or 
twenty minutes, immediately followed 
by ionization (cataphoresis) for ten 
to fifteen minutes. In chronic joint 
cases and chronic lumbago, the author 
orders for ionization a 2 per cent, 
solution of lithium iodide, directing 
that the negative ion (the iodine) 
should be driven into the tissues. In 
acute lumbago a 2 per cent, solution 
of sodium salicylate should be used 
at the first sitting or two in order to 
relieve the pain. In the later stages 
of a muscular fibrositis a rapidly in- 
terrupted faradic current is beneficial, 
but it should be so weak as not 
to cause any muscular contraction. 
Massage is very useful in the later 
stages, but it should not be employed 
until it causes no pain, and should be 



very gentle at first. During the pain- 
ful stage of muscular rheumatism rest 
of the affected muscles is required, 
but later on exercises of the muscles 
are of great benefit. They should be 
performed on rising in the morning 
and followed by a cold or tepid bath 
and brisk rubbing of the skin with a 
rough towel. No special dieting is 
required; moderation should be the 
keynote. Porous linen underwear is 
the most suitable for rheumatic indi- 
viduals. A. P. Lufif (Lancet, Mar. 12, 
1910). 

The distinguishing pathological fea- 
tures of fibromyositis, according to J. 
Madison Taylor, are plastic adhesions 
of contiguous structures exerting 
compression on sensory nerve-fibers 
which need to be set free mechan- 
ically. While this can be achieved by 
various agencies such as by counter- 
irritation, blisters, electricity, etc., the 
most radical, prompt, and permanent 
relief is by expert manipulation, such 
as deep pressures with lateral traction, 
torsion, etc. ; the best is by lifting and 
separating the adherent structures, 
thus freeing sensory fibers from com- 
pression. In some cases, fibromyo- 
sitis is so persistent as to remain for 
many years a source of disablement, 
lameness, or deformity, resisting all 
medication, yet can be removed by 
manipulation in a few days. Best re- 
sults from medication by sodium ben- 
zoate and Martin H. Fisher's alkaline 
solution by colonic irrigation. 

In any of the ordinary manifesta- 
tions of chronic rheumatism, as lum- 
bago, sciatica, pleurodynia, or cepha- 
lalgia, and with any obscure myalgic" 
or neuralgic pain in any part of the 
body, a careful investigation should 
be made of the fibromuscular tissues 
of the affected areas. In the more 
recent diffuse cases there is general 
tenderness of these tissues. Usually, 
either with or without such general 
tenderness, one will find areas which. 



26 



RHEUMATISM (LEVISON AND SAJOUS). 



are definitely, often exquisitely, ten- 
der to touch. General treatment for 
a feverish attack, with the ordinary 
pain-relieving drugs, generally suffices 
to cure. If the pain is at all localized 
a single thorough application of mas- 
sage may result in cure in this early 
stage. y\ny discoverable cause, such 
as gastrointestinal irregularities, must 
be removed. During the more acute 
exacerbat'ons sodium salicylate pi"o- 
duces some relief, but recurrence is 
probable indefinitely. To obtain a 
permanent cure it is absolutely nec- 
essary to obtain locally a complete 
dispersal of the indurations. Coun- 
terirritation by blistering or cau- 
tery produces relief, but nothing is 
so efficient as the rubbing in of oil 
of gaultheria.. Important also are 
massage and systematic exercises. 
Acupuncture is of great use in reliev- 
ing pain, but does not produce com- 
plete dispersal of the infiltrations. In 
cases of fibrous nodules w^hich will 
not yield to simpler measures, and 
which by pressing on nerves cause 
persistent pain, excision is not only 
advisable but necessary. Telling 
(Lancet, Jan. 21, 1911). 

Senile rheumatism described as a 
separate morbid condition. Being 
one of the manifestations of aging, it 
can neither be prevented nor cured. 
Pain can, however, be relieved. The 
pain usually disappears soon after 
joint motion has ceased, but if it per- 
sists, application of moist heat, fol- 
lowed by an inunction of 2 per cent. 
cocaine liniment or ointment, using 
an animal base, will generally give 
relief. Sweet butter is an excellent 
base for this purpose. To prevent its 
becoming rancid 2 grains (0.12 Gm.) 
of sodium benzoate to the ounce (30 
Gm.) should be added. The constitu- 
tional measures are hygienic and 
medicinal, the latter consisting of the 
intermittent use of phosphorus and 
the iodide of arsenic. I. L. Nascher 
(Amer. Med., Dec, 1911). 

The writer emphasizes the value of 
local heat, especially dry, radiant 
heat, combined with ionization, in 
muscular rheumatism. In lumbago. 



the static current may be substituted 
for ionization. Massage is useful, but 
it should not be applied to the af?ccted 
part itself, but around it. A. P. Luft 
(Med. Rec, Aug. 16, 1913). 

GONOCOCCAL (GONORRHEAL) 
RHEUMATISM. 

Gonococcal rheumatistn, or arthritis, 
is an acute inflammation of one or 
more articulations occurring during the 
course of gonorrhea and caused by in- 
vasion of gonococci in the joints. 

SYMPTOMS.— The condition ordi- 
narily appears in the acute stage of 
gonorrhea. In some cases the lesion of 
the joints is only revealed by arthralgia : 
i.e., intense pain without swelling. This 
condition is particularly observed in 
the small joints of the foot. The pain 
is worst in the evening and is aggra- 
vated by movements. The arthralgia 
may also precede the evolution of 
gonorrheal arthritis or continue for 
some time after the disappearance of 
the swelling. 

In other cases the affected joint be- 
comes the seat of an effusion of fluid, 
giving rise to little or no pain. This, 
effusion disappears very slowly, and 
often leaves stiffness or fibrous adhe- 
sions in the joint. This form of the 
disease is most frequently observed in 
the knee. 

Ordinarily gonococcal rheumatism in 
its mode of invasion and evolution very 
much resembles the acute form of ar- 
ticular rheumatism. It differs from 
that disease, however, in attacking only 
one or a few articulations at the same 
time, and in that the affected joints 
remain involved for a longer period. 
Again, gonococcal arthritis does not 
migrate so suddenly from one joint to 
another as the acute articular affection. 
No joint, however, is immune, and 
even those which ordinarily escape dur- 



RHEUMATISM (LEVISON AND SAJOUS). 27 

ing the course of rheumatic fever, e.g., gonococcal rheumatism is a rare occur- 

the articulations of the jaws and the rence. It only happens when the infec- 

neck, may be attacked by the gonococ- tion with gonococci is complicated with 

cal arthritis. invasion of pyogenic organisms. The 

The pain is of extreme intensity. It chronic form of gonococcal rheumatism 

is aggravated by movements and by often gives rise to contracture of the 

pressure over the swollen articulation, joints or periostitis of the epiphyses. 

Many painful points are also found. DIAGNOSIS. — The diagnosis is 

Tumefaction is ordinarily very marked ; easy when the urethral discharge is still 

it is caused both by effusion into the present, but difficult when it is not. 

joint and by edema of the overlying The disease may be confounded with 

structures. The skin over the affected acute articular rheumatism and with 

joint is hot and tense. osteomyelitis. In gonococcal arthritis, 

Commonly the patient tries to allevi- but few articulations are attacked at 

ate the pain by keeping the affected once. The mode of development of the 

joint semiflexed. If he is allowed to arthritis, the extent to which the periar- 

remain in this position, contraction of ticular tissues are involved, the rela- 

the extremity may result. tive absence of constitutional symp- 

Gonococcal rheumatism does not toms, the inefficacy of the salicylates, 

affect the articulations alone. The and, if possible, the demonstration of 

serous bursse and the sheaths of the gonococci in the blood or the affected 

tendons in the proximity of the diseased joint constitute the chief distinguish- 

joint are always involved ; sometimes ing features. 

they alone suffer, the inflammatory ETIOLOGY. — Gonorrheal rheu- 

process being thus periarticular — gono- matism is caused by an infection with 

coccal tenosynovitis. The muscles of gonococci, and it is only observed as 

the affected extremity are always af- the consequence of a gonococcal ure- 

fected and generally become atrophied, thritis. Many authors have found the 

In some cases one joint only is at- gonococci in material taken from the 

tacked; the pain is, then, as a rule, still affected joints or synovial sheaths, and 

more excruciating and the effusion some have even observed them, in the 

greater than in the polyarticular form, blood. The disease attacks both sexes 

The acute stage of the disease is not equally; it may occur in children as 

usually of long duration. After some well as in adults. It develops in 2 per 

days or a week the pain declines and cent, of all gonorrhea cases in the male 

the effusion diminishes. The disease sex. 

rarely disappears completely, however; PROGNOSIS. — The prognosis as 

one or more joints remain somewhat to life is good, but very often the dis- 

stiff and painful several months. The ease results in stift'ness of the affected 

so-called painful heel of gonorrhea is joint and weakness of the limb, due 

the result of a periosteal inflammation to atrophy of its muscles. 

of the OS calcis, with or without exos- TREATMENT. — Treatment by 

tosis. In some instances chronic gono- means of drugs given internally is 

coccal arthritis assumes the form of a not of great value; the salicylates 

persistent serous effusion. have little or no influence on the 

Suppuration of the joints affected by course of the affection. The same 



28 



RHEUMATISM (LEVISON AND SAJOUS). 



appears to be true of potassium 
iodide, except in the chronic cases. 
Ihe use of syrup of ferrous iodide in 
doses of 10 to 60 minims (0.6 to 4 c.c.) 
three times a day has been recom- 
mended by J. C. Wilson. Oil of gaul- 
theria in doses of from 5 to 20 drops 
every two hours in milk has also 
been recommended, \\niere acute or 
chronic gonorrhea coexists, every 
means should be taken to overcome 
the urethral focus of infection. In 
the more chronic cases the use of 
tonics such as strychnine, arsenic, 
and codliver oil may prove of value. 
Gonococcus vaccines have given 
excellent results in a certain propor- 
tion of chronic cases. Antigonococcic 
serum lias also been used. 

At the onset of gonorrheal rheuma- 
tism, the patient should receive a 
purgative of calomel to be followed 
by citrate of magnesia, or salts, or a 
dose of castor oil. He should be put 
on a light diet with plenty of liquids, 
such as soup, milk, alkaline waters, 
etc., avoiding stimulating articles of 
diet as tea, coffee, spices, and alcohol. 
The bowels should be kept regular 
and the patient drink plenty of water. 
H necessary, a mild diuretic can be 
given. Codeine or morphine should 
be given if necessary for the pain. 
Phenyl salicylate, S grains (0.3 Gm.) 
and antipyrin, 3 grains (0.2 Gm.) 
may be given every three or four 
hours for the fever. The oil of gaul- 
theria in doses of 20 drops three 
times a day, or potassium iodide, 
has be:n recommended. Every case 
should be treated at once with anti- 
gonococcic serum or gonococcic vac- 
cine. The combined bacterins seem 
to be more useful than the single- 
strain cultures. The initial dose is be- 
tween 10 and 20 million, running the 
same up every second, third, or fourth 
day, until about 50 million are being 
given every second or third day. Im- 
provement is usually noticed within a 
week or ten days, but the treatment 



should be continued until all the 
symptoms have su])sided, which may 
take from four to six weeks. Broe- 
man (Med. Rev., Sept., 1913). 

Local treatment is of great impor- 
tance. The affected joint should be 
placed on a splint in a proper position 
and alxsolute rest of the extremity 
enjoined. Pain may be relieved by 
various anodyne measures, e.g., hot 
and cold applications, tlic ice-bag, 
ointments of ichthyol or belladonna, 
a wet dressing- of lead-water and 
laudanum, or, if necessary, a hypo- 
dermic injection of morphine. Coun- 
terirritation may be instituted by 
means of turpentine or iodine. 
Gaucher procures relief for several 
hours by bathing the part for half an 
hour in a mixture of equal parts of 
an aqueous emulsion of black soap 
and of oil of turpentine; 5 to 6 
fluidrams (20 to 25 c.c.) of this mix- 
ture are used with 6 gallons (25 
liters) of water. The genitals should 
be anointed vvith petrolatum before 
the bath is administered. Balzer 
uses the following ointment: — 

IJ Acidi salicyiici. 

Old tcrebinthin<c, 

Adipis lance hydrosi.aa Siiss (5 Gm.). 

Adipis benzoinati 'Siij (100 Gm.). 

Fiant unguentum. 

In the intervals between local pro- 
cedures a bandage should be applied 
as firmly as is practicable. Or, a 
plaster-of-Paris dressing may be 
used for complete immobilization, 
applied under anesthesia if necessary. 
Straightening of the limb under anes- 
thesia is necessary if fixation in a 
faulty position has already taken 
place. 

In cases in which acute pain has 
subsided massage and passive move- 
ments are of value to assist in res- 



RHUBARB. 



29 



toration of joint mobility. Dry hot- 
air baths, Bier's passive hyperemia, 

and counterirritation with bhsters or 
the thermocautery are also very 
serviceable measures in the more 
chronic cases. The last two pro- 
cedures are especially indicated in 
cases characterized by hydrarthrosis. 
Compression is also of value in these 
cases. 

Where the above fail to bring re- 
lief within a reasonable period, and 
especially if the effusion becomes 
purulent, arthrotomy should be per- 
formed and the joint evacuated and 
irrigated with an antiseptic or sterile 
saline fluid, according to indications. 
Aspiration followed by injection of 1 
to l^A fluidrams (4 to 6 c.c.) of a 
1 : 4000 solution of mercury bichloride 
has been recommended by P.alzer and 
others, but the more radical pro- 
cedure in general meets with greater 
favor. Bres, in 20 cases, after incis- 
ing the joint, removed the diseased 
synovial membrane and injected 
dilute tincture of iodine or a weak 
solution of zinc chloride. All his 
cases recovered completely. 

F. Levison, 

Copenhagen, 

AND 

L. T. DE M. Sajous, 

Philadelphia. 

RHEUMATOID ARTHRITIS. 

See Joints, Surgical Diseases of, 

RHIGOLENE. See Petroleum. 

RHINITIS AND OTHER NA- 
SAL DISORDERS. See Index. 

RHUBARB. — Rhubarb, or rheum 
(U. S. p.), is the root of Rheum officinale 
and of other undetermined species of 
Rheum (nat. ord., Polygonacc;c) : a plant 
indigenous to Asia (China, India, Tar- 
tary, and Thibet), but which is cultivated 



in America and elsewhere. It contains 
extractive, sugar, starch, pectin, lignin, 
salts, several unimportant alkaloids, a 
glucoside, and acids, one of which, chry- 
sophanic acid, is used in medicine. In 
commerce two sorts are recognized, — 
the Chinese and the European, — the for- 
mer of which is considered the better. 
It occurs in irregular cylindrical or 
conical, flattened pieces, which are gener- 
ally perforated, are covered with a light 
yellowish-brown powder, and have fre- 
quently a wrinkled surface. Beneath the 
powder the color of the root is reddish 
brown, mottled with lighter hues. The 
root is dense and hard and has a bitter 
and somewhat astringent taste and a 
peculiar aromatic odor. When chewed, 
the root is gritty (due to the presence 
of crystals of calcium oxalate), and im- 
parts a yellow color to the saliva. 
European rhubarb is inferior to the 
Chinese variety; powdered rhubarb is also 
inferior, and, if not adulterated, at least 
is generally made up of inferior, dam- 
aged, worthless or worm-eaten material. 

PREPARATIONS AND DOSES.— 
Rheum, U. S. P. (the root). Dose, 5 to 
30 grains (0.3 to 2 Gm.). 

Extractum rhei, U. S. P, (extract of 
rhubarb). Dose, 5 to 15 grains (0.3 to 

1 Gm.). 

rUiidextractum rhei, U. S. P. (fluid- 
extract of rhubarb). Dose, K to 1 
dram (1 to 4 c.c). 

Mistura rhei composita, N. F. (rhubarb 
and soda mixture). Fluidextract of rhu- 
barb, 15; fluidextract of ipecac, 3; bicar- 
bonate of soda, 35; glycerin, 350; spirit 
of peppermint, 35; water, sufficient to 
make 1000 parts. Dose, 1 to 4 drams (4 to 

16 c.c). 

Pilulcc rhei compositce, U. S. P. (com- 
pound rhubarb pills, containing rhubarb, 

2 grains; aloes, V/2 grains; myrrh, 1 
grain). Dose, 1 to 3 pills. 

Pulz'is rhei coinpositus, U. S. P. (com- 
pound rhubarb powder or Gregory's pow- 
der, containing rhubarb, 25; magnesia, 
65; ginger, 10 parts). Dose, ^ to 1 
dram (2 to 4 Gm.). 

Syrupus rhei, U. S. P. (syrup of rhu- 
barb, containing fluidextract of rhubarb, 
10 per cent.). Dose, 2 to 6 drams 
(8 to 25 c.c). 



30 



RIGGS'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS). 



Syni/^us rhei aromaticus, U. S. P. (aro- 
matic syrup of rhubarb, containinjif 
aromatic tincture of rhubarb, 15 per 
cent.). Dose, 2 to 6 drams (8 to 25 c.c). 

Tinctura rhci, U. S. P. (tincture of rhu- 
barb — rhubarb 20 per cent.). Dose, Yz to 
2 drams (2 to 8 c.c). 

Tinctura rhci aromatica, U. S. P. (aro- 
matic tincture of rhubarb — rhubarl) 20 per 
cent.). Dose, K' to 3 drams (2 to 12 c.c). 

POISONING BY RHUBARB.— Rhu- 
barb is not generally considered poison- 
ous, but a case has been reported in 
which the internal administration of 
rhubarb gave rise to a hemorrhagic 
eruption of macules, pustules, and blebs. 
The mucous membranes were also af- 
fected, and free hemorrhage from the 
urethra occurred. 

THERAPEUTICS.— Rhubarb is an ex- 
cellent stomachic tonic in atonic dyspep- 
sia associated with deficient biliary and 
intestinal secretion. It is a remedy espe- 
cially adapted to those of relaxed habit, 
but inadmissible when an hyperemia of 
the mucous membrane exists. 

Rhubarb is a valuable remedy in simple 
constipation, where we wish to unload 
the bowels without affecting the general 
system. The root is often chewed by 
adults to relieve constipation. In chil- 
dren the syrup is a palatable preparation 
for this purpose; the pill or compound 
pill may be used by adults. 

Constipation and hemorrhoids depend- 
ing upon pregnancy are benefited by the 
administration of rhubarb. 

In the summer diarrhea of children, 
with green stools, the aromatic syrup of 
rhubarb may be employed to empty the 
bowel of its fermenting contents before 
giving direct treatment. The diarrhea of 
indigestion in children and adults is re- 
lieved by the aromatic syrup or by the 
mixture of rhubarb and soda. 

In children, when constipation is re- 
placed by diarrhea, if any ordinary laxa- 
tive is used, rhubarb is an available rem- 
edy on account of its secondary astrin- 
gent action. 

Functional disturbance of the liver with 
deficient biliary secretion is relieved by 
the administration of rhubarb, either 
alone or, better, combined with blue mass. 

Rhubarb is an efficient remedy in duo- 



denal catarrh and in catarrh of the biliary 
ducts with jaundice, especially in chil- 
dren. White, pasty, or clay-colored stools 
and a skin of an earthy or jaundiced hue 
are indications for rhubarb. 

RHUS POISONING. See Der- 
matitis Venenata. 

RIBS, DISEASES AND INJU- 
RIES OF. See Index. 



RICKETS. See Bones, Diseases 



OF. 



RIGA'S DISEASE. See Mouth, 
Lips, and Jaws, Diseases of. 

RIGGS'S DISEASE; PYOR- 
RHEA ALVEOLARIS (SPONGY 

GUMS).— DEFINITION.— This is a 

pyogenic inflammation of the gums, 
apparently starting from the gum mar- 
gins, and associated with a suppuration 
of the peridental membrane of the 
roots of the teeth, which tends to 
loosen the latter by detaching them 
from the surrounding alveolar tissue. 
SYMPTOMS.— The earliest symp- 
toms noted, as a rule, are sensitive- 
ness, redness, and perhaps swelling of 
the gums, with a tendency to bleed 
when touched. The development of 
the disease being insidious, these 
signs are in reality those of an ad- 
vanced morbid process, a fact shown 
in many cases by the presence of 
granular pustules around and under 
the edges of the gums, due to the for- 
mation of deep pockets between the 
latter and the teeth. An offensive 
breath and a coated tongue are usual, 
and periodical attacks of toothache 
also, though in some cases pressure 
over the gums will always elicit a dull 
pain ; occasionally the latter becomes 
continuous. Loosening of the teeth 
in their sockets occurs quite fre- 
quently. A mild stomatitis is some- 
times witnessed, and persistent glos- 



RIGG'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS). 



31 



sitis with irregular exfoliation, leaving 
red patches, may also occur. 

The disease is obviously a chronic 
one, but it may be attended with acute 
exacerbations lasting from a few days 
to several weeks, during which the 
gums become very tender and bleed 
spontaneously. During the ulcerative 
process the submaxillary or cervical 
glands may enlarge and become pain- 
ful, suggesting tuberculosis. 

Pyorrhea alveolaris is not infre- 
quently the cause of systemic dis- 
turbances. 

Many cases of septic fever of un- 
known origin and conditions diag- 
nosed as malignant endocarditis, as 
well as many deaths attributed to 
acute septicemia, would have been 
correctly diagnosed if the oral cavity 
had been examined. Many deaths 
due to alveolar abscess, tooth extrac- 
tion, and septic oral conditions have 
been reported. 

C. H. Mayo interestingly stamps 
pyorrhea as the cause, not the re- 
sult, of systemic disturbances. Ap- 
pendicitis being caused by septic oral 
conditions has been confirmed by the 
bacteriological investigations of Lanz 
and Tavel. 

Tooth extraction has given a com- 
paratively high death rate. All cases 
presenting pus should be afforded 
free drainage until danger from in- 
fection has passed. A. W. Fossier 
(N. Y. Med. Jour., Aug. 7, 1915). 

Many cases of alveolar abscess are 
erroneously diagnosed as pyorrhea 
alveolaris. This grave error was 
much more common before the ad- 
vent of rontgenology. It has been 
found that the toxemia resulting 
from a dental granuloma is far 
greater than from a pyorrheal dis- 
charge. M. L. Rhein (Surg., Gynec. 
and Obstet., Jan., 1916). 

DIAGNOSIS.— The differential 
diagnosis is sometimes difficult to 
establish from alveolar disease over- 
lying necrosis due to poisoning by 



lead, mercury, phosphorus, or other 

elements used industrially. Syphilitic 

or tuberculous lesions of the gums 

may also cause confusion. Scurvy, 

now rarely encountered, also causes 

gingival lesions resembling closely 

pyorrhea. In these various conditions 

the history of the case and the course 

of the disease are frequently of major 

assistance in the differentiation from 

true pyorrhea. 

Unlike dental caries which is un- 
common in "native" races, pyorrhea 
alveolaris is probably as common in 
them as in the civilized. It is very 
common in domesticated animals, 
while almost unknown in wild ani- 
mals. The disease has increased 
enormously in civilized countries dur- 
ing the last few decades. Inefficient 
mastication, whether due to pre-exist- 
ing disease of the teeth or to the food 
being too refined and soft, is a power- 
ful etiological factor. Marginal gin- 
givitis having been set up, infection 
with organisms rapidly follows, and a 
rarefying osteitis, commencing at the 
inner margin of the sockets, soon sets 
in. Lime salts from the pus become 
deposited on the roots of the teeth, 
at first around the necks just under 
the gum margin, and later on the 
deeper parts. This in itself acts as 
an irritant, and so a vicious circle is 
set up which must be broken before a 
cure can be effected — the tartar causes 
ulceration, which produces more pus, 
which forms more tartar. Gibbs 
(Edinb. Med. Jour., Oct., 1917). 

ETIOLOGY.— Pyorrhea alveolaris 
was for a time thought to be due to 
the Endamcba gingiz'alis (Gros, 1849), 
but later work seems to have definitely 
shown that this organism cannot be 
considered the causative agent. As a 
matter of fact, there appear to be both 
predisposing causes and exciting causes 
which play a role in the production of 
pyorrhea. Among the former are sys- 
temic diseases, localized malnutrition. 



2>2 



RIGG'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS). 



frail bony investment of the teeth, and 
trauma resulting from malocclusion 
(Merritt). As for the exciting cause, 
it seems probable that anything causing 
prolonged irritation of the gums may 
act as such. Bacteriological studies on 
the disease have been based largely on 
cases in a frankly purulent state; it is 
considered highly probable, however, 
that a non-purulent inflammatory stage 
of the condition, due to trauma and 
constitutional influences, may occur be- 
fore micro-organismal infection takes 
place. 

Such constitutional affections as 
gout, diabetes mellitus, and other states 
indicative of deficient or imperfecl 
metabolism, while incriminated as pre- 
disposing causes of pyorrhea, are by 
no means essential in its production. 
According to Maurice Roy, unduly 
early senile absorption of the bony 
tooth sockets constitutes the first stage 
of pyorrhea. The most plainly evident 
predisposing cause is age. After the 
thirtieth year its development is ob- 
served with growing frequency, until 
about the fiftieth year. In persons who 
take good care of their teeth through 
cleanliness, expert attention to avoid 
cavities, badly fitting crowns or fill- 
ings, etc., pyorrhea tends to remain in 
abeyance. Its harmful eftects are 
likely to follow opposite conditions, 
particularly uncleanliness and trau- 
matisms of the gums by accumula- 
tion of tartar, especially when de- 
bilitating diseases, such as gout, 
anemia, and infectious diseases, have 
weakened the bacteriolytic activity of 
the buccal secretions. Autointoxica- 
tion of intestinal origin is also 
thought to favor the development of 
the disease, possibly by overtaxing 
the defensive functions of the body, 
thus favoring infection from any 



source. It may likewise occur in tooth- 
less gums when the false teeth are 
not kept scrupulously clean. 

There is a frroup of cases which 
the writer suspects to be caused by 
the spirochete of Vincent's angina. 
He has seen several cases on record 
where mothers have developed this 
condition, and it has been followed 
by an illness in tlie child, first diag- 
nosed as diphtheria and then as Vin- 
cent's angina. There are also cases 
caused by the Treponema pallida. W. 
Sterling Hewitt (Dental Cosmos, 
Oct., 1915). 

The teeth, as end-organs, are the 
first to exhibit a diminution in im- 
munity to infection, if any form of 
malnutrition exists. If, by exercise, 
massage, and other hygienic meas- 
ures, circulation in the ultimate capil- 
laries is kept moving, the gums and 
peridental tissue will frequently re- 
tain their immunity, even though 
malnutrition be present. Pyorrhea 
alveolaris is a result of malnutrition 
plus infection, and also most fre- 
quently plus irritation, and it is 
greatly intensified if arteriosclerosis 
of the ultimate capillaries sets in. 
All forms must commence with some 
form of gingivitis, but the tissues 
vary markedly in clinical appearance. 

The writer is inclined to recognize 
particular types of pyorrhea accord- 
ing to the associated disease, e.g., dia- 
betic pyorrhea, tuberculous pyorrhea, 
etc. The symptomatology and treat- 
ment difTer in each type. The prog- 
nosis largely depends on the possibil- 
ity of curing the malnutritional fac- 
tor. Often the pyorrheal changes 
will appear long before the signs of 
the underlying disease are sufficiently 
developed to permit a diagnosis. 
There are cases, however, in which a 
decrease in the functional power of 
the teeth themselves is the chief 
cause. This is usually due to such 
conditions as loss of one or more 
teeth, irritation from unpolished fill- 
ings, etc. Often when the underlying- 
constitutional cause is found it will 
not be recognized as such, but will 



RIGG'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS). 33 

be regarded as secondary to the pyor- may initiate pneumonia. The chronic 

rhea. M. L. Rhein (Jour. Amer. processes of the series are benefited 

Med. Assoc, Feb. 10, 1917)). ^^ autogenous vaccines in most in- 

Hartzell's work points strongly to ^^^^^^^^^ j^ ^^^^^^ ^^^^^ ^^ ^,^^ ^.^^^^^ 

the importance of the streptococcus m . 

pyorrhea, indicating that approxi- there IS apparently no pus. This seem- 

mately three-fourths of the bacterial ing absence may be due to shallow or 

content of the pus pockets is made up wide open pockets, the pus being 

of pyogenic cocci of the Streptococcus cashed away by the oral secretions as 

7'fru/fl;;.y and staphylococcus types, and ... ■. ■ r j •. u j 

. ., r .1 rapidly as it IS lormed. or it may be due 

the remammg one-tourth ot other . . -^ 

organisms. Personal observations to an inactive phagocytosis, or both 

relative to the occurrence of strepto- (Merritt). 

cocci, staphylococci, and pneumococci TREATMENT. — One important 

in pyorrhea would place streptococci feature in this connection is the pres- 

in the first rank as regards frequency, r i. j. i- i i .li i j 

, , , . .1-1 ence of tartar, particularly the hard 

staphylococci next, while pneumo- ^ •' 

cocci are observed in only a small variety derived from blood-serum and 
percentage of cases. A. W. Lescohier made up of various phosphates, car- 
(Jour. Amer. Med. Assoc, Feb. 10, bonates and often dark in color. This 
^^^'^- is a calculus which forms along the 
PATHOLOGY. — The inflamma- edges of the gums and peridental 
tory process starts at the margin of membrane. The first step is to care- 
the gum and soon involves the dental fully rid the teeth of any tartar that 
periosteum and surrounding alveolar may be present, and the gums of 
wall. The latter being a medullary decayed teeth, badly fitting crowns 
space in the maxilla, a morbid process and fillings, angular projections from 
similar to osteomyelitis develops, end- the latter, etc. In a word, the patient 
ing in necrosis. The endameba buccalis should be placed in the hands of a 
can not infrequently be detected, and all competent dentist, who should be 
the more common pyogenic bacteria informed of the end in view, 
may occur in the lesions. The pneu- Introduction of an accessory medi- 
mococcus is also found in most cases, cinal treatment of pyorrhea followed 
As shown by Rosenow and Billings, the discovery of Barrett and that an 
there is a close connection between actively motile Endameba buccalis 
the pneumococcus and the streptococ- occurred in pyorrhea pus pockets, 
cus, some strains of the latter taken The fact that dysentery, due to an 
from tonsillar crypts having been con- endameba, yielded promptly to emetine 
verted under various cultural con- hydrochloride suggested its use, a 
ditions into typical pneumococci. solution of J^ per cent, of this salt 
The same convertibility occurs in the being injected into the pockets. In 
streptococci of pyorrhea. Hence the several instances of the 13 cases 
fact that, precisely -as in the case with treated the pus disa]:)peared in 24 
the tonsils, streptococci in pockets of hours and the gums assumed a health- 
pyorrhea alveolaris may give rise to ier appearance after the third or sec- 
rheumatic joint infections, arthritis ond injection. Bass and Johns (New 
deformans, endocarditis, pericarditis, Orleans Med. and Surg. Journal, vol. 
exophthalmic goiter, goiter, gastric Ixvii, p. 456, 1914) then tried the 
ulcer, etc., while the pneumococcus drug hypodermically, giving y^ grain 

8—3 



34 



RIGG'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS). 



(0.03 Gm.) until the amebse had dis- 
appeared and keeping up the effects 
by local applications of 2 or 3 minims 
(0.12 to 0.18 CO.) of the fluidextract 
of ipecac to the gums with the tooth- 
brush after carefully cleansing the 
teeth. These agents sometimes seemed 
curative in mild cases, but when the 
morbid process was severe the organ- 
ism was observed to recur. 

Of 190 cases examined 187 showed 
endamebffi. Of the 187, 78 have been 
treated for pyorrhea. Of the 78 
treated, none lost their endamebse 
permanently. The condition of the 
gums and teeth was greatly improved 
in 3 cases, moderately improved in 9 
cases, slightly improved in 22 cases, 
while 41 cases remained the same; 
the results were doubtful in 2 cases 
and 1 case became worse. Practically 
all that were found negative for 
endamebjE at the conclusion of the 
injections were found positive for 
endamicbae from two weeks to four 
months later, in spite of using a 
solution of ipecac as a mouth-wash. 

Emetine is an amebicide, but alone 
will not cure pyorrhea alveolaris. J. 
S. Ruofif (U. S. Public Health Report, 
Reprint, 320, 1916). 

Suspecting that pyorrhea is due to 
certain spirochetes. Kritchevsky and 
Seguin have used neoarsphenamine. 
Good results in 60 cases reported 
from mercury succinimide injections. 
In the pyorrheal secretions numbers 
of large spirochetes were observed 
which generally disappeared almost 
completely as a result of the injec- 
tions. Among 244 cases the spiro- 
chetes were found in large number in 
three-fourths of all instances. In 
healthy mouths, they were usually 
absent or few. Six to 10 injections of 
0.1 to 0.6 Gm. of neoarsphenamine 
among 42 patients all showing numer- 
ous spirochetes caused disappearance 
of the latter in 29 cases, in the ab- 
sence of all local treatment. Clinical 
improvement was marked. The treat- 
ment recommended for pyorrhea is as 



follows: Intravenous injection of 0.1 
to 0.3 Gm. of neoarsphenamine. If 
contraindications or special technical 
difficulties exist, intramuscular injec- 
tions of mercury succinimide. Where 
the tooth is entirely loosened and the 
alveolar process destroyed, the tooth 
had best be removed. If the process 
is but partly involved the roots 
should be scraped and even carefully 
polished. Fluorine salts assist in 
breaking up the tartar. Neoarsphena- 
mine should also be introduced in the 
pyorrheal pockets in solution or 
powder form. Recurrence is obviated 
only by persistent, careful cleansing 
of the teeth. B. Kritchevsky and P. 
Seguin (Presse med.. May 13, 1918). 

Some observers have reported good 
results from the use of a stock bacterin 
or autogenous vaccine. 

In the cases studied by the writers, 
streptococci predominated, but were 
associated in some instances, either 
with Staphylococcus aureus, S. albus, 
or with S. citreus. In 2 cases there 
. was found an association of the strep- 
tococcus and of the Bacillus pHeuinojiice, 
once with the Micrococcus catarrhalis, 
and twice with a pneumococcus. 

A sensitized vaccine against the 
streptococcus, staphylococcus, pneu- 
mococcus, and bacillus of Friedlander 
was thereupon prepared. For M. 
catarrhalis a Wright vaccine was 
made. Vaccine injections were then 
made. After 2 injections, when the 
antibodies began to take hold, a 
mechanical and dental treatment — 
Younger's — was begun. After from 
4 to 5 injections, it was found impos- 
sible, either by microscopic examina- 
tion or by cultures, to discern the 
presence of the bacteria. The authors 
have kept in touch with a number of 
cases for six months after treatment. 
These cases have shown no recur- 
rence. Bertrand and Valadier (N. Y. 
Med. Jour., Jan. 10, 1914). 

A stock vaccine may be used, either 
sensitized or unsensitized, or an 
autogenous vaccine prepared from 
the pus pockets may be employed. 
If the autogenous is preferred, care 



ROCKY MOUNTAIN SPOTTED FEVER (WITHERSTINE), 



35 



should be taken to select an experi- 
enced bacteriologist for its prepara- 
tion. If an unsensitized bacterin is 
employed, the initial dose advised is 
ISO million of the mixed bacteria; 
250 to 750 million may be given as 
the initial dose if the sensitized cul- 
tures are employed. Subsequent 
doses are injected at intervals of 
seven to ten days, gradually increas- 
ing or decreasing according to indi- 
cations. If the reactions are too 
severe, the doses should be reduced 
or temporarily discontinued. Every 
dose should be carefully gauged by 
the effect obtained from the preced 
ing dose. If no improvement follows 
the initial dose, subsequent injections 
should be increased until amounts 
large enough to produce a mild clin- 
ical reaction (demonstrated by symp- 
toms of malaise and possibly aggra- 
vation of the local symptoms) are 
reached. If a marked clinical reac- 
tion occurs after a dose, characterized 
by rising temperature, the next dose 
should be smaller. F. E. Stewart (N. 
Y. Med. Jour., Aug. 7, 1915). 

Injections of succinimide of mer- 
cury (1 grain — 0.065 Gm.) weekly are 
announced as curative by Wright and 
White (U. S. Navy), from one to six 
doses having been sufficient in their 
cases besides the local measures. 
Copeland (Dental Cosmos, Feb., 
1916) confirms these observations. 
He usd a B. W. 8z Co. glass syringe 
holding 40 minims (2.5 c.c.) and a 
No. 26 intramuscular needle, the 
solution being % grain (0.013 Gm.) 
of mercuric succinimide to 4 minims 
(0.25 c.c.) of hot, sterile distilled 
water. The injections are made into 
the buttock after sterilization of the 
skin. 

The writer advocates surgical meas- 
ures, removing the diseased tissues 
under novocaine anesthesia, then pack- 
ing with iodoform gauze to promote 
drainage and granulation. The pa- 
tient is shown how to flush his teeth 



with warm saline solution after eat- 
ing for the post-operative week. This 
operation does not cure pyorrhea; it 
is the only method which prevents 
secondary infection. Nodine (Dental 
Cosmos, Ixiii, 345, 1921). 

The writer resorts to gingivoec- 
tomy, cutting away under local anes- 
thesia all loose, infected and diseased 
tissues to eradicate peridental infec- 
tion. He claims to have obtained a 
cure in 90 per cent, of his cases. 
Ziesel (Dental Cosmos, Ixiii, 352, 
1921). 

Time will probably show that such 
active surgical procedures are un- 
necessary to cure pyorrhea. 

Prophylaxis is an important fea- 
ture : scrupulous cleanliness of the 
mouth and regular visits to the den- 
tist to check any incipient disorder of 
the teeth or gums. 

C. E. DE M. Sajous, 

Philadelphia. 

RINGWORM. See Trichophy- 
tosis. 

ROCHELLE SALTS. See Po- 
tassium AND Sodium Tartrate. 

ROCKY MOUNTAIN SPOT- 
TED FEVER (TICK FEVER).- 

This eruptive disease has been known 
in the valley of the Bitter Root River 
in Western Montana and in Idaho 
since 1873, although the first specific 
reference to it in literature was made 
in 1896 by the Surgeon General of the 
Army in his annual report. The dis- 
ease has since been reported from 
nearly all the States in the Rocky 
Mountain group, California, Colorado, 
Idaho, Montana, Nevada, Oregon, 
Utah, Washington and Wyoming. 
Cases have also been reported from 
the District of Alaska. The disease is 
especially interesting on account of 
its geographical limitation, seasonal 
prevalence, intimate association with 



36 



ROCKY MOUNTAIN SPOTTED FEVER (WITHERSTINE). 



wood ticks, and variation in severity 
in different localities. It is api)arently 
confined to the American Continent, 
being- found only between 40° and 47° 
north, and at an average elevation of 
between 3000 and 4000 feet above 
sea level. It prevails exclusively in 
the spring and early summer; in the 
Bitter Root cases the earliest was 
March 17 and the latest July 17. 
Those whose duties take them into 
the brush and expose them to the bite 
of ticks are subject to the disease, 
especially stockmen, sheep herders, 
miners, prospectors, lumbermen and 
ranchmen. The greatest morbidity is 
in persons between 15 and 50 years of 
age, presumably because they are 
most actively engaged in outdoor 
work, and, for the same reason, males 
most often fall victims to this disease. 
It is not contagious ; 2 cases of the 
disease have never been observed in 
the same family the same season. 

SYMPTOMS.— Incubation.— There 
is a stage of incubation lasting from 
three to ten days, usually about seven. 
For a few days the patient complains 
of chilly sensations, malaise, and nau- 
sea, then has a distinct chill and takes 
to his bed. Soon there are pains in 
the back and head, and a feeling of 
soreness in the muscles and bones, 
with a sensation as if the limbs were 
in a vice. The bowels are constipated 
and the tongue is covered with a 
heavy white coat, but red at the tip 
and edges. The conjunctivae are con- 
gested, and later become yellowish in 
color. The urine is usually scanty 
and contains albumin and casts. 
Epistaxis, at times alarming, is 
always present, and slight bronchitis 
appears after a few days. 

Fever. — Before the distinct chill 
there is a slight rise of temperature 



in the afternoon, l)ut little or no fever 
in the morning. After the chill there 
is an abrupt rise, with a gradual 
increase of the fever in the evening, 
and a slight morning remission, the 
maximum being usually reached be- 
tween the eighth and twelfth days. 
In a favorable case it then gradually 
falls, reaching normal about the four- 
teenth to the eighteenth day, usually 
going to subnormal for a few days. 
In fatal cases the fever remains higli 
(104° to 106° F.— 40° to 41.1° C.;, 
and the morning remissions are either 
absent or very slight. Yet the tem- 
perature may rise to 105° or 106" F. 
(40.6° to 41.1° C.) by the seventh or 
eighth day, ending in favorable cases 
by lysis on tlie ninth or tenth day. 

Circulation. — The pulse is acceler- 
ated out of all proportion to the 
temperature, a pulse of 120 being 
common with a temperature of only 
102° F. (38.8° C.) ; the pulse usually 
varies from 110 to 140; it is weak and 
thready ; a full, strong pulse is excep- 
tional ; during the first week it may 
be dicrotic. There is a progressive 
diminution in the number of red 
blood-cells, but when the temperature 
reaches normal an increase begins. 

The white blood-corpuscles are 
increased in number varying from 
8,000 to 12,000; an average differen- 
tial count would give : polymorphonu- 
clear leucocytes, 77 .7 per cent. ; large 
mononuclears, 11.4 per cent.; small 
lymphocytes, 10 per cent. ; eosino- 
philes, 0.9 per cent. ; the most marked 
feature being an increase in the large 
mononuclears. The hemoglobin is 
steadily but slowly decreased — it may 
go as low as 50 per cent. The blood 
will not agglutinize Bacillus typhosus; 
fresh and stained blood contains three 
forms of the pathogenic parasite. 



ROCKY MOUNTAIN SPOTTED FEVER (WITHERSTINE). 



17 



A sudden rise in the leucocyte 
count is an unfavorable sign. 

Eruption. — On the third day the 
eruption usually appears, first on 
the wrists and ankles, then on the 
arms, legs, forehead, back, chest, and, 
last and least, on the abdomen. 
Although the other portions of the 
body may be closely covered by the 
eruption, it is always scanty on the 
abdomen. 

The spots are at first bright-red, 
always macular, and in size from a 
pinpoint to a split pea, at first dis- 
appear on pressure and return quickly ; 
in severe cases they rapidly become 
darker, even purplish in color. From 
the sixth to the tenth days of the 
disease, the spots do not disappear on 
pressure and are decidedly petechial 
in character. In favorable cases, 
about the fourteenth day they lose 
their petechial character and disap- 
pear slowly on pressure. The erup- 
tion may assume the appearance of a 
turkey-egg, the skin being flecked 
with small, brownish spots. The erup- 
tion fades as the fever declines, but 
an access of fever, a warm bath, or a 
free perspiration will bring it out dis- 
tinctly. Desquamation begins when 
convalescence is well advanced and 
is general. In very severe cases there 
may be gangrene of the fingers, toes, 
and more frequently of the skin of the 
scrotum and penis. Jaundice is 
always present, first in the conjunc- 
tivae and later involving the entire 
cutaneous surface. 

The Gastrointestinal Tract. — The 
tongue is covered at first with a 
heavy, whitish coat, except on the 
edges and tip, which are red ; later the 
coating is dark brown and sordes 
covers the teeth. The appetite is often 
good throughout the first week. 



although there may be slight nausea. 
In fatal cases the nausea increases 
during the second week and persists. 
Constipation is always present and 
continuous. Gurgling is seldom found 
m the right iliac fossa and tympanites 
is never excessive. Moderate increase 
in the size of the liver is present, and 
the spleen is enlarged early and may 
extend one or two inches below the 
ribs. Black vomit is common. 

The Urinary Tract. — The urinary 
output is one-half the normal. Albu- 
min in small amount is present in all 
cases, associated with granular, hya- 
line, and epithelial casts. Nephritis 
may appear early in the history of 
the case. 

The Respiratory Tract. — The res- 
pirations are always accelerated, be- 
ing usually from 26 to 40 per minute, 
although they may reach 50 to 60; 
they are regular but often shallow. 
Slight bronchitis always appears in 
the second week. In fatal cases lobar 
pneumonia is a frequent complication. 
Epistaxis is generally observed from 
the beginning of the second week. 

Nervous System. — Headache and 
pains in the back are usually severe 
during the first week. A feeling of 
soreness in the muscles and bones, 
often very severe, even in mild 
cases, is present and persists until 
recovery. The mind is usually clear, 
in severe cases, until a few hours 
before death. 

DIAGNOSIS. — Diagnosis Is usually 
easy in cases occurring in infected 
localities, which present a history of 
tick-bites and the typical symptoms of 
this disease; a blood examination will 
clear up any doubtful case. There 
are, however, five diseases to which 
it bears more or less close resem- 
blance from which this disease must 



38 



ROCKY MOUNTAIN SPOTTED FEVEK (VVITHERSTINE). 



be differentiated: deni^ue, cerebro- 
spinal menins^itis, pcliosis rhcumatica, 
typhoid and ty])hus fevers. 

Dengue is a disease of tropical and 
subtropical countries, while spotted 
fever is found at elevations of from 
3000 to 4000 feet above sea-level 
The swollen joints, polymorphic erup- 
tion (never petechial) over the joints, 
apyretic period, and short duration of 
dengue would distinguish it. 

Cerebrospinal meninyitis is marked 
by the characteristic stiffness of the 
neck muscles, photophobia, extreme 
sensitiveness to sudden noises, head- 
ache, rigidity of the muscles of the 
back and neck, and a rash which is 
not only irregular in location, but also 
in appearance. 

Peliosis rhemnatica is a compara- 
tively rare disease in which there is 
a characteristic sore throat associated 
with multiple arthritis, purpura, and 
urticaria. 

Typhoid fever clinically closely 
resembles spotted fever except in the 
rose-colored spots (papular) which 
appear first on the abdomen, the diar- 
rhea, the Widal reaction, the presence 
of typhoid bacilli in blood-cultures, 
and the absence of the parasites 
formed in the red blood-cells of spot- 
ted fever. 

Typhus fever so closely resembles 
spotted fever that cases of typhus 
fever occurring in a spotted-fever dis- 
trict, without a blood examination and 
close clinical observation, might easily 
be counfounded with it. In typhus 
fever, however, we have a larger incu- 
bation, absence of tick-bites, the erup- 
tion which appears first on the abdo- 
men and chest, and an intensely con- 
tagious character. Typhus is, more- 
over, especially prevalent during the 
winter months, and not during the 



late spring and early summer, and is 
accompanied by marked nervous 
sym])toms. 

ETIOLOGY.— Spotted fever is 
caused by a protozoan parasite which 
is transmitted to man thrrjugh the 
bite of the wood tick (Dermacentor 
andersoni). To Wilson and Chowning 
belongs the credit of discovering this 
parasite, three forms of which have 
been identified by John F. Anderson, 
the most common is a single ovoid 
body, refractile, situated within the 
red blood-cell, usually near its edge, 
and closely resembling the earliest 
intracorpuscular parasites of estivo- 
autumnal malaria. When the blood 
upon the freshly prepared slide is 
warmed the parasite quite rapidly 
projects pseudopodia and may change 
its position slightly. A second form, 
somewhat rarer, is larger, and larger 
at one end and showing there a dark, 
granular spot; this form is also ame- 
boid. The third form, arranged in 
pairs, is pyriform in shape, with the 
smaller end approaching, and in some 
cases being united by a fine thread. 
The parasite is developed in the 
female tick and the young ticks, after 
being hatched, transmit the infection. 
The female gets her infection by bit- 
ing one convalescent from spotted 
fever. 

Three types of the spotted fever 
parasite can be recognized: (1) An 
extranuclear bacilius-Hke form with- 
out chromatoid granules, relatively 
large and only present in ticks dur- 
ing the initial multiplication of the 
parasites; (2) a relatively small rod- 
shaped form with chromatoid gran- 
ules, probably the same form seen 
within nuclei in sections of ticks, and 
rarely in smooth muscle cells in the 
blood-vessel of mammals; and (3) a 
relatively large lanceolate paired form 
present in ticks and in the blood and 



RUBELLA (CRANDALL). 



39 



lesions in mammals. The name Der- 
macentroxcmis rickcttsi is proposed. 
S. B. Wolbach (Jour. Med. Re- 
search, Nov., 1919). 

PROGNOSIS. — The mortality 
varies between 70 and 90 per cent. 
Death usually occurs between the 
sixth and the twelfth day. There is 
no relation between abundance of the 
eruption and severity of the disease. 

TREATMENT. — Quinine bimuri- 

ate in 15-grain (1 Gm.) doses every 
six hours, preferably hypodermically, 
has yielded excellent results in the 
hands of Wilson and Anderson. Qui- 
nine sulphate, 15 grains (1 Gm.), may 
be given by mouth every four hours, 
and should be begun as soon as the 
■diagnosis is made, and persisted with 
in decreasing doses as convalescence 
begins. The heart should be sup- 
ported with strychnine, whisky (egg- 
nog), or other cardiac stimulants. 

The severe pain in the head and 
back, during the first week, may be 
relieved by the use of Dover's powder 
or morphine sulphate. It is well to 
flush the kidneys through the use of 
copious draughts of water. Warm 
sponge baths or packs are useful in 
controlling the fever. The room 
should be darkened and free from 
noise. In the way of diet milk, butter- 
milk, broths, soft-boiled eggs, and 
moistened toast may be given. 

In the way of prophylaxis, Ander- 
son advises that as soon as a person 
is bitten by a tick the insect should 
be removed and 95 per cent, carbolic 
acid applied to the spot. If there is 
difficulty in removing the tick, Ander- 
son suggests the application of 
ammonia, turpentine, kerosene, or car- 
bolized petroleum to it. 

The treatment is rather unsatisfac- 
tory, being mainly supportive and 



symptomatic; the only drug of much 
service is sodium citrate given in- 
travenously to the limit of tolerance 
from the start. Sixty c.c. of a 5 per 
cent, fresh sterile solution may be 
given intravenously twice daily. H. 
C. Michie and H. H. Parsons (Med. 
Rec, Feb. 12, 1916). 

C. Sumner Witherstine, 

Philadelphia. 

RUBELLA, Rotheln, German 

measles. 

DEFINITION. — Rubella is an 
acute, infectious, contagious disease 
of mild character, presenting some- 
what variable symptoms and running 
a favorable course. Its identity as a 
disease, siii generis, was long doubted. 
There is now no question, however, 
that it is a distinct entity among dis- 
eases, though it strongly resembles 
in its different manifestations measles 
and scarlet fever. No better state- 
ment of present beliefs regarding its 
true character has been made than 
that of Griffith, which is as follows : 
"(1) rubella is a contagious, eruptive 
fever, and not a simple affection of 
the skin; (2) it prevails independently 
either of measles or of scarlet fever; 
(3) its incubation, eruption, invasion, 
and symptoms diff'er materially from 
both of these diseases ; (4) it attacks 
indiscriminately and with equal sever- 
ity those who have had measles and 
scarlet fever and those who have not, 
nor does it protect in any degree 
against either of them; (5) it never 
produces anything but rubella in 
those exposed to its contagion ; (6) it 
occurs l)Ut once in the indi\'idual." 

PERIOD OF INCUBATION.— 
This period is, according to Holt, 8 
to 16 days, the limits being 5 to 22 
days ; Rotch, 21 days ; Edwards, 7 to 
14 days ; Plant, 1 to 3 weeks ; Smith, 
about 2 weeks. These figures clearly 



40 



RUBELLA (CRANDyVLL). 



show that the period of incubation is 
of considerable length and extremely 
variable. The indefiniteness arises 
not so much from lack of observation 
as from variability in the disease. To 
say that the period of incubation is 
about two weeks is probably as cor- 
rect and definite a statement as can 
be made. 

SYMPTOMS.— The symptoms of 
rubella are extremely variable, so 
much so in fact that we must agree 
with Rotch that it is impossible to de- 
scribe a typical case in such a way 
that the disease can be certainly di- 
agnosticated in a sporadic case. 
Many cases, however, run a fairly 
consistent and characteristic course. 
The invasion is seldom severe. In 
some cases there is a prodromal stage 
lasting a few hours ; in others the 
rash is the first svmptom to be ob- 
served. The fever is rarely high and 
often does not rise above 100° F. 
(37.8° C), but commonly, when at its 
height, on the first day of the erup- 
tion, it reaches 101° or 102° F. (38.3° 
or 38.9° C). It occasionally rises to 
104° F. (40° C.) or more. The 
drowsiness, stupor, and other evi- 
dences of serious illness so frequently 
seen at the height of measles are 
rarely, if ever, seen in rubella. A 
child with a bright and very exten- 
sive eruption will frequently show no 
sign of general illness. 

In my own experience sore throat 
has been the rule. The tonsils and 
pharynx are red and swelled and there 
is pain on swallowing. This is oc- 
casionally so marked as to be sug- 
gestive of scarlet fever; the vomiting 
so common at the outset of that dis- 
ease, however, is rarely present. A 
secondary sore throat which comes on 
as the disease is subsiding was first 



noted by Eustace Smith as very char- 
acteristic of rubella. It certainly oc- 
curs in some cases. Koplik's spots 
do not ai)pear. The symptoms of the 
]M-imary angina subside on the second 
or third day and rapidly disappear. 
There are no catarrhal symptoms in 
most cases, but occasionally slight 
suffusion of the eyes and a mild ca- 
tarrh will render the diagnosis from 
measles more difficult. Albuminuria 
is rarely if ever present, and the diazo- 
reaction is extremely rare. Moderate 
leucocytosis occurs during the incu- 
bation period, but disappears as the 
eruption fades. 

Hematological diagnosis of ro- 
theln. Three cases under treatment 
appeared clinically as measles, but 
the first soon proved itself rotheln. 
Two weeks later two similar cases 
were admitted. The writer then com- 
pared the blood-counts of the cases 
with examples of true measles. He 
found that in rotheln at the high 
point of the disease there was none 
of the disappearance of eosinophiles 
which characterizes measles; nor was 
there the leucopenia regarded as 
normal in the latter disease. Schwaer 
(Mitnch med. Woch., May 27, 1913). 

Enlargement of the postcervical 
and suboccipital glands is a very con- 
stant and very characteristic symp- 
tom of rubella. Numerous small 
glands may almost invariably be felt 
behind the sternomastoid well down 
toward the shoulder; they rarely be- 
come very large and never suppurate. 
They may be felt most distinctly 
when the rash is at its height, and 
disappear rapidly. While they aid 
materially in diagnosis, and may per- 
haps be called diagnostic, they are 
certainly not pathognomonic, for they 
may at times be met in measles and 
in rare cases be found in scrofulous 
children without febrile symptoms. 



RUBELLA (CRANDALL). 



41 



Most salient features by which one may distinguish rubella from measles 
and scarlet fever are as follows, as given by N. S. Manning: — 





Rubella. 


Measles. 


Scarlet Fever. 


Invasion 


Nil. 


Three to five days, 
with pyrexia and 
conjunctival and 
bronchial catarrh. 


Twelve to twenty- 
four hours, pyrexia, 
headache, and 
vomiting. 


Catarrh 


Slight or absent. 


Marked conjunctivitis, 
coryza, cough, etc. 


Absent. 


Eruption 


Appears on face and 
chest as bright, 
pink-red maculre, 
first under the cuti- 
cle, which become 
raised, with tend- 
ency to spread and 


Appears on face as 
darkish-red, slight- 
ly raised papules ; 
extends to trunk 
and limbs ; papules 
become confluent, 
but distribution is 


Appears on chest as 
diffuse general red- 
ness of skin. 




form irregular 
patches or become 
diffuse. 


more uniform. 




Throat-lesions 


Slight swelling and 
injection of fauces. 


Fauces injected. 


All the faucial struct- 
ures acutely in- 
flamed, swelled and 
red, or ulcerated. 


Tongue 


Furred. 


Furred. 


Thickly furred, which 
begins to strip off 
in twenty- four or 
forty-eight hours. 


Superficial lymphatic 
glands 


Always enlarged in 
axillt-e, groins, and 
behind stcrnomas- 
toid muscle in neck. 


May be enlarged at 
angles of jaw and 
behind sternomas- 
toid muscle. 


leaving raw sur- 
face, with enlarged 
papill?e. 

May be enlarged at 
angles of jaw and 
behind sternomas- 
toid muscle. 


Desquamation 


Absent or very slight. 


Branny. 


Characteristic peeling 
off of large pieces 
of epithelium. 



Forchheimer describes an exan- 
them which is seen in the mouth as 
the exanthem appears on the body. It 
usually lasts about twenty-four hours. 
"It consists of a macular, distinctly 
rose-red eruption, upon the velum of 
the palate and the uvula, extending 
to but not on the hard palate. The 
spots are arranged irregularly, not 
crescentically, of the size of large 
pinheads, very little elevated above 
the level of the mucous membrane, 
and do not seem to produce any reac- 
tion tipon it." 

The eruption appears first upon tlie 



face or forehead and extends rapidly 
over the neck, trunk, and limbs. The 
whole body is usually covered within 
twenty-four hours. Occasionally the 
child will wake in the morning with 
a rash covering the greater portion of 
the body. In many cases the rash is 
limited to small areas, the greater 
portion of the body escaping entirely. 
It is more constant upon the face than 
any other region. In some cases the 
rash continues not more than twenty- 
four hours, but, as a rule, it is present 
from two to four days. Itching is 
common at the outset. 



42 



RUBELLA (CRANDALL). 



A slight, scaly desquamation may 
follow the disappearance of the rash, 
but in many cases no desquamation 
can be detected. This is particularly 
true when inunction of the body has 
been practised. 

The eruption consists of papules or 
maculopapules of a red or rose-red 
color. They vary greatly in size, 
varying from a pin's-head point to a 
large blotch. Tliis multiform charac- 
ter is one of the peculiarities of the 
eruption of rubella. IMost of the 
spots are smaller than those of 
measles and larger than those of scar- 
let fever. They vary in size on differ- 
ent portions of the body, and even in 
the same region the rash will be 
found, as a rule, to be made up of 
small dots interspersed with larger 
and irregular-shaped spots or blotches. 
It lacks the uniformity of the rash 
seen in scarlet fever or measles. The 
rash more commonly resembles that 
of measles and it is frequently impos- 
sible to make a diagnosis from it 
alone. Edwards has recently alleged 
that he has not seen the rash resem- 
ble that of scarlet fever. That is not 
my experience. I have frequently 
seen a rash consisting of small points 
grouped closely upon a reddened 
skin that looked extremely like scarlet 
fever. Search over the body, in such 
cases, however, will usually reveal 
small areas of eruption composed of 
maculopapules, appearing as large 
spots. These are commonly found 
upon the arms, wrists, or hands. I 
quite agree with those who describe 
a scarlatinal and rubeolar type of 
eruption. I have seen these two types 
well marked in two children of the 
same family exposed at the same time, 
and ill in the same room. The rash 
of one, consisting of large maculo- 



papules ver}' strongly resembled 
measles; that of the other, consisting 
of much finer points on a reddened 
skin, as strongly resembled scarlet 
fever. 

A disease was described by Clem- 
ent Dukes, of England, in 1900, to 
which he gave the name of "Fourth 
Disease." The condition which is de- 
scribed is virtually that which I have 
here described as the scarlatinal form 
of German measles. The differential 
diagnosis given by Dukes between 
German measles and fourth disease 
describes a condition identical except 
as to the rash. He admits that in 
the same patient the eruption some- 
times resembles measles and may 
change later to a scarlatinal type. 

The subject has received extended 
study since Dukes promulgated the 
theory of a fourth disease. After care- 
ful observation of 1335 cases seen in 
the London Fever Hospital, Beards 
and Goldie did not see any they felt 
thev could record as fourth disease. 
AVatson Williams made a very care- 
ful study of 2)2 cases of rubella and 
questions the existence of a fourth 
disease. Pleasants, of Baltimore, also 
concludes that the existence of a new 
exanthematic disease has not been es- 
tablished. After an extended review 
of the whole subject Ker concludes 
that the fourth disease is either mild 
scarlet fever or atypical rubella. 
From study of the literature and from 
considerable experience it seems to me 
that we have not sufficient evidence 
to warrant us in describing a fourth 
disease. 

ETIOLOGY.— Analogy leads to 
the belief that rubella is caused by a 
specific micro-organism, but the germ 
has not yet been discovered. It is 
contagious, though not as strongly so 



RUE. 



43 



as scarlet fever and measles. Its con- 
tagious power at times seems to be 
very slight. It is most contagious 
when the eruption is at its height. It 
is rarely, if ever, seen under six 
months, but after that age no period 
of life is exempt. It is most common 
between 5 and 10 years. The recur- 
rence of true rubella is rare. The 
disease usually occurs in epidemics, 
which are most common in the spring. 
COMPLICATIONS AND SE- 
QUELJE. — No other infectious dis- 
ease is so free from complications. 
This is, in fact, one of the most 
marked peculiarities of rubella. Even 
varicella sometimes shows a serious 
complication : that of gangrene. No 
such serious symptom is likely to arise 
in rubella. The pneumonia, otitis, 
erysipelas, and multiple abscesses, 
which in rare instances have been re- 
ported as accompanying rubella, are 
perhaps not in every case a complica- 
tion, but rather a coincidence. 

The writer reports the following 
unusual case: The patient, a male, de- 
veloped, after a few days of sore 
throat, stifi neck, malaise, and moder- 
ate fever, a rash having the distribu- 
tion and appearance of German meas- 
les and accompanied by an enlarge- 
ment of superficial glands, notably 
those of the neck. Before the exan- 
them had faded the patient began to 
complain of stiffness and tenderness 
in the knees and ankles, and soon 
all the interphalangeal joints of the 
fingers presented the spindle-like 
swelling commonly seen in rheuma- 
toid arthritis. There was no exacer- 
bation of temperature and neither 
cardiac nor other complication. A 
fortnight from the appearance of the 
rash all the symptoms were subsiding, 
and in the six months there was only 
an occasional transient stififness in 
the fingers. D. A. Alexander (Lan- 
cet, ii, p. 921, 1907). 



In an epidemic in an institution 
for children, out of 80 cases 2 
children developed chickenpox before 
recovering from rubella, 1 developed 
rubella before recovering from chic- 
kenpox, and 1 child had a severe 
ulcerative stomatitis. May Michael 
(Arch, of Pediat., Aug., 1908). 

PROGNOSIS. — Death from ru- 
bella is extremely infrequent. In rare 
cases in which it occurs it is usually 
the result of some pulmonary disease, 
occurring either as a complication or 
as a coincidence. 

TREATMENT.— Rubella requires 
very little, if any, treatment. Mild 
treatment appropriate to any febrile 
condition is permissible, but if the 
patient is kept in bed while the fever 
and rash continue, and is anointed 
daily with oil, further treatment will 
rarely be required. Symptoms must 
be treated as they arise. In most 
cases the disease as such is of but lit- 
tle importance, its chief interest lying 
in its diagnosis, owing to its resem- 
blance to two more serious diseases. 

Floyd M. Crandall, 

New York. 

RUBEOLA. See Measles. 

RUE.— Rue (Ruta) is the leaves of 
Riita gravcolens (fam. Rutaceas), a peren- 
nial herb or undershrub of Southern Eu- 
rope, but cultivated elsewhere as a domes- 
tic medicinal herb. The important con- 
stituent (0.06 per cent.) of rue is a volatile 
oil, colorless or slightly yellow and of low 
specific gravity, and extremely unpleasant 
and odorous. It was official in the U. S. 
r. from 1870 to 1890. Rue also contains 
a glucoside (rutin-rutic or rutinic acid) 
which is yellow and crystalline and ap- 
parently identical with the barosmin of 
buchu, considerable sugar, and possibly a 
volatile alkaloid. 

PREPARATIONS AND DOSES.— 
Oleum mice (oil of rue). Dose, 3 to 6 
minims (0.20 to 0.40 c.c), in capsule. 

Ruta (rue). Dose, 15 to 30 grains (1 to 



44 



SACCHARIN. 



2 Gm.), usually in infusion. Neither 
preparation is now official. 

PHYSIOLOGICAL ACTION.— Rue is 
a local irritant and vesicant. Internally 
it is a stimulant, carminative and em- 
menagogue. In large doses it is an 
irritant poison, producing severe gastro- 
enteritis, vomiting, abdominal pain and 
meteorism, bloody stools, suppression of 
urine, or stranguary, and epileptiform con- 
vulsions. Dimness of vision with con- 
tracted pupils are observed. Abortion may 
result from toxic doses. It has some spe- 
cial action upon the genitourinary tract, 
and is eliminated in the breath, the urine, 
and in the perspiration. It is rarely fatal, 

THERAPEUTIC USES.— In medicinal 
doses it is given as a uterine stimulant in 



atonic amenorrhea, menorrhagia, and me- 
trorrhagia. Its employment as an aborti- 
facieiit entails great danger to the mother. 
Hysteria, especially when associated with 
amenorrhea, is benefited by the drug. It 
has also been friund xiscful in flatulence 
and infantile convulsions. In defective 
activity of the sexual organs, it acts as 
an aphrodisiac and emmenagogue. The 
bruised leaves of rue laid upon the fore- 
head has been used by Phillips to check 
epistaxis. Added to liniments rue has 
found favor as an application to the 
chest in chronic bronchitis. A decoction 
of the fresh leaves may be used as 
an injection against seatvirorms (oxyuris) 
and has often been given internally to 
expel roundworms (ascarides). W. 



SACCHARIN. —Saccharin (benzo- 
sulphiiiidum, U. S. P.; glusidum, Br.; 
neosaccharin; gluside; benzoyl sulphonic- 
imide), or the anhydride of orthosulpha- 
mide- — benzoic acid (C7H5NO3S), is a coal- 
tar derivative obtained commercially from 
toluene discovered by C. Fahlberg in 1879. 
Saccharin occurs as a white, crystalline 
powder, nearly odorless, having an in- 
tensely sweet taste even in dilute solu- 
tions. Iti is soluble in 250 parts of water 
and in 25 parts of alcohol, and but slightly 
soluble in ether and chloroform. It read- 
ily dissolves in 24 parts of boiling water. 
Saccharin dissolves also in glycerin. Its 
solubility in water is promoted by the ad- 
dition of sodium bicarbonate in the pro- 
portion of 2 parts to 3 of saccharin. 
Saccharin forms soluble salts with the hy- 
drates of the alkaline metals. It melts at 
220° C. (428° F.), and when fused with 
potassium or sodium hydroxide it forms 
salicylic acid. It is 300 times sweeter than 
cane-sugar. 

Sodium saccharin, also known as soluble 
saccharin, soluble gluside, and crystallose, 
is prepared by neutralizing an aqueous 
solution of saccharin with sodium car- 
bonate or bicarbonate and slowly crys- 
tallizing the solution. It occurs in color- 
less crystals, very soluble in water, in- 
tensely sweet to the taste, and not dis- 



colored by concentrated sulphuric acid. 
It is a favorite substitute for saccharin be- 
cause of its greater solubility. 

Saccharin when present in food products 
or mixtures may be separated by extract- 
ing the saccharin from an acidulated 
solution of the substance with ether, sep- 
arating the ether and then evaporating the 
ethereal solution thus obtained. The aver- 
age dose of saccharin is 3 grains (0.2 Gm.). 

PHYSIOLOGICAL EFFECTS. — Sac- 
charin apparently is not decomposed in 
the body, as it is excreted by the kidneys 
imchanged; the urine, however, does not 
so readily undergo fermentation and the 
chlorides are increased. Mathews and 
McGuigan, in studying the effects of sac- 
charin on oxidation and digestion, report 
that it has a marked retarding action on 
oxidation in the blood and muscles, and 
also on the action of the digestive juices, 
especially those of the salivary glands 
and pancreas. Its prolonged use is likely 
to cause digestive disorders. When in- 
jected into the circulation of an animal, it 
produces depression and stupor, followed 
by labored respiration, similar to asphyxia. 
The writers attribute these effects to its 
inhibitory action on the enzymes of the 
blood and tissues, which also explains the 
headaches and other symptoms its use 
often gives rise to. It is believed to be a 



SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 45 



general protoplasmic poison in that it in- 
hibits fiearly all the fermentative processes 
of the body, and interferes with and 
diminishes general bodily metabolism. 
Saccharin has antiseptic properties which, 
however, are impaired in the presence of 
an acid medium. 

POISONING BY SACCHARIN.— 
Large doses of saccharin are capable of 
producing marked toxic symptoms, as in 
a case reported by Luth, where a woman 
having swallowed about 30 grains (2 Gm.) 
of saccharin was found in a state resem- 
bling that of alcoholic intoxication. She 
was unconscious and foamed at the mouth. 
Her face was flushed and she suffered 
from convulsive attacks, with choking. 
The respirations were rapid and the pulse 
weak, very rapid, intermittent, and irregu- 
lar. Poisoning by saccharin is rather rare. 

TREATMENT OF POISONING.— In 
the foregoing, under artificial respiration 
and massage of the heart, the pulse within 
half an hour became stronger and regular, 
and the respiration became normal. After 
forty-five minutes the patient awoke and 
felt quite well. 

THERAPEUTIC USES. — Saccharin is 
chiefly used as a sul)stitute for sugar in the 
diet of obese and diabetic patients. Tablets 
containing Yi grain (0.03 Gm.) of saccharin 
combined with a small quantity of sodium 
bicarbonate are conveniently carried by 
these patients to be used in tea, coffee, etc. 
It may also be prescribed in the form of 
a syrup containing 10 parts of saccharin 
and 12 parts of sodium bicarbonate in 1000 
parts of distilled water, made with gentle 
heat at 104° F. (40° C). Saccharin in small 
doses has been used in acid dyspepsia and 
in chronic cystitis with ammoniacal urine. 
Two parts of saccharin in solution with 
3 parts of sodium bicarbonatei forms a 
good tooth-wash. Aphthae yields to sac- 
charin; 15 grains (1 Gm.) of saccharin are 
dissolved in IJ/2 ounces (50 c.c.) of alcohol, 
of which a teaspoonful is added to a half- 
cup of water, and used to wash the mouth 
thoroughly four or five times a day. It 
may be used to cover the taste of quinine, 
1 part of saccharin to 2 of quinine be- 
ing used. As saccharin retards the action 
of all the digestive ferments, it is contra- 
indicated in cases in which digestion is 
already impaired. W. 



SALICYLIC ACID, THE SAL- 
ICYLATES, AND SALICIN.— 

Salicylic acid, chemically ortho-oxy- 
benzoic acid [C6H4(OH)COOH] is 
an organic acid existing naturally in 
the oils of wintergreen (GaiUthcria 
procumbcns) and of sweet birch 
(Bctula Icnta) in combination as 
methyl salicylate. It was first arti- 
ficially made in 1874 by Kolbe, who 
produced it from phenol, cailstic soda, 
and carbon dioxide with the aid of 
moderate heat and subsequent treat- 
ment with hydrochloric acid. The 
solubility of salicylic acid in water, 
normally relatively slight, is increased 
by the addition of the phosphates, 
citrates, or acetates of the alkalies, 
and by borax (sodium biborate). 
Pure salicylic acid should be free from 
color and from the odor of phenol ; 
when heated on platinum foil, it 
should leave no ash. 

Various salts of salicylic acid are 
official. There are also in common 
use a number of other substances con- 
taining the salicyl radicle, including 
such drugs as acetyl-salicylic acid and 
salicin. The last named, a glucoside 
obtained from the bark of several 
species of Salix and Populiis, supplied 
the original name for the entire group 
of drugs, the word salicyl being 
derived from Salix. 

PREPARATIONS AND DOSE. 
— the following salicyl preparations 
are official : — 

Acidum salicylicnm, U. S. P. (sali- 
cylic acid), occurring in fine prismatic 
needles or a bulky, white powder, 
with a slight odor of wintergreen and 
a taste at first sweetish, then acrid. It 
is soluble in 308 parts of water at 77° 
F. and in 14 jxirts of boiling water, 
and in 2 parts of alcohol, in 60 parts 
of glycerin, and in 2 parts of olive oil 



46 



SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 



(with the aid of heat). Dose, 5 to 20 
grains (0.3 to 1.3 Gm.) ; average, 7i/2 
grains (0.5 Gm.). 

Ammonii salicylas, U. S. P. (ammo- 
nium saHcylate) [CcH4(OH)COO- 
NH4], occurring in prisms or plates 
or as a white, crystalHne powder, 
odorless, with a saline, bitter taste 
and sweetish after-taste. It is freely 
soluble in water and alcohol. Dose, 
3 to 15 grains (0.2 to 1 Gm.) ; aver- 
age 4 grains (0.25 Gm.). 

Sodii salicylas, U. S. P. (sodium sali- 
cylate) [C6H4(OH)COONa], a white 
microcrystalline or amorphous pow- 
der, occasionally with a faint pink 
coloration, and having a sweetish, 
saline taste. It is soluble in 0.8 part 
of water and in 5.5 parts of alcohol, 
and also dissolves in glycerin. Dose, 
5 to 20 grains (0.3 to 1.3 Gm.). 

Strontii salicylas, U. S. P. (stron- 
tium salicylate) [(C6H4(OH)COO)o- 
Sr+2H20], a white, crystalline 
powder with a sweetish, saline taste, 
soluble in 18 parts of water and in 66 
parts of alcohol. Dose, 5 to 20 grains 
(0.3 to 1.3 Gm.). 

Phenylis salicylas, U. S. P. (phenyl 
salicylate; salol) [C6H4(OH)COOCg- 
H5], a white, crystalline powder with 
a slightly aromatic odor and taste, 
practically insoluble in water, but 
soluble in 5 parts of alcohol and freely 
soluble in ether, chloroform, and oils. 
Synthetic or from Gaultheria or Be tula. 
Dose, 3 to 15 grains (0.2 to 1 Gm.) ; 
average, 7^^ grains (0.5 Gm.). 

Methylis salicylas, U. S. P. (methyl 
salicylate ; an artificial or synthetic 
oil of wintergreen) [CgH4(OH)- 
COOCHoJ, a colorless liqvud with a 
strong wintergreen odor, a sweetish 
strongly aromatic taste, and a specific 
gravity of 1.18. It is sparingly soluble 
in water, but dissolves readily in alco- 



hol. Dose, 5 to 20 minims (0.3 to 
1.3 c.c). Chiefly usecf externally. 

Salicinitm, U. S. P. (salicin) [C13- 
llisOx), a glucoside obtained from 
several species of the willow (Salix) 
and poplar (Populus), occurring in 
colorless, silky, crystalline needles, 
prisms, or a white, crystalline powder, 
odorless, but with a strongly bitter 
taste. It is soluble in 21 parts of 
water and in 71 parts of alcohol, but 
is insoluble in ether and chloroform. 
Dose, 10 to 30 grains (0.6 to 2 Gm.). 

Oleum betulcc, U. S. P., VIII (oil of 
betula; oil of birch), a volatile oil 
obtained by maceration and distilla- 
tion from the bark of the sweet birch, 
Betula lenta. Consists mainly of 
methyl salicylate. Dose, 5 to 20 
minims (0.3 to 1.3 c.c). Chiefly 
used externally. 

Oleum gaulthericc, U. S. P. VIII (oil 
of gaultheria or wintergreen), a vola- 
tile oil di'stilled from the leaves of 
Gaultheria procumbens, consists mainly 
of methyl salicylate. Dose, 5 to 20 
minims (0.3 to 1.3 c.c). Chiefly used 
externally. 

Spiritus gaulthericc, U. S. P. VIII 
(spirit of gaultheria), made by mixing 
5 parts by volume of oil of gaultheria 
with 95 parts of alcohol. Dose, 30 
minims (2 c.c). 

Bismuth subsalicylate, physostig- 
mine salicylate, quinine salicylate, and 
cafifeine sodiosalicylate (N. F.) are 
described in the articles on Bismuth, 
Physostigma, Cinchona, and Caffeine, 
respectively. 

Among the salicylic preparations 
recognized in the National Formulary 
are: — 

Lithii salicylas, N. F. (lithium 
salicylate) [C6H4(OH)COOLi], a 
white or grayish-white powder with 
a sweetish taste, deliquescent in a 



SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 



47 



moist atmosphere. It is freely soluble 
in water and alcohol. Dose, 5 to 20 
grains (0.3 to 1.3 Gm.). 

Elixir litliii salicylatis, N. F. (elixir 
of lithimii salicylate). Dose, 2 flui- 
drams (8 c.c), containing 10 grains 
(0.6 Gm.) of lithium salicylate. 

Elixir sodii salicylatis, N. F., similar 
to the preceding. 

Glyccrogclatimim acidi salicylici, N. 
F. (glycerogelatin of salicylic acid), 
containing 10 per cent, of the acid. 
Used locally, being melted by gentle 
heating and applied with a camel's 
hair brush. 

Liquor antisepticiis, N. F. (anti- 
septic solution, Lister), containing 30 
per cent, of alcohol, 2.5 per cent, of 
boric acid, 0.12 per cent, of methyl 
salicylate and of sodium salicylate, 0.6 
per cent, of sodium benzoate, 0.5 per 
cent, of eucalyptol, 0.1 per cent, of 
thymol, and 0.03 per cent, of oil of 
thyme. Dose, 1 fluidram (4 c.c). 
Chiefly used locally. 

Liquor antisepticiis alkalimis, N. F. 
(alkaHne antiseptic solution), contain- 
ing 15 per cent, of glycerin, 3.2 per 
cent, of potassium bicarbonate and of 
sodium borate, 0.8 per cent, of sodi- 
um benzoate, 0.04 per cent, of oil of 
gaultheria, and 0.02 per cent, of thymol, 
of eucalyptol, and of oil of peppermint, 
colored purplish red with cudbear; 6 
per cent, of alcohol. Used locally, 
diluted with 2 to 5 parts of warm water. 

Pasta dnci, N. F. (Lassar's zinc or 
zinc-sahcyl paste), containing 2 per 
cent, of salicylic acid, with zinc oxide. 
Used externally. 

Piilvis antisepticus, N. F. (soluble 
antiseptic powder), a mixture of 
powdered boric acid, 86.6 per cent.; 
zinc sulphate, 12.5 per cent.; salicylic 
acid, 0.5 per cent.; phenol, eucalyptol, 
menthol, and thymol, of each 0.1 per 



cent. Used as dusting powder or in 
5 per cent, solution. 

Pulvis talci composites, N. F. (sali- 
cylated talcum powder), consisting of 
salicylic acid, 3 parts; boric acid, 10 
parts, and powdered talc, 87 parts. 
Used as dusting powder. 

Mulla acidi salicylici, N. F. (salicy- 
lated salve mull or ointment), a 10 
per cent, preparation of salicylic acid 
in benzoinated lard and suet, spread 
on gauze or mull, to be applied to the 
skin where penetration by the sali- 
cylic acid is desired. 

Mulla creosoti salicylata, N. F. 
(salicylated creosote salve mull), like 
the preceding, with addition of 20 per 
cent, of creosote. 

UNOFFICIAL PREPARATIONS. 

— Among the unofiicial salicylic prep- 
arations used internally are : — 

Acetylsalicylic acid (aspirin) \Cq- 
H4.0(CH3CO).COOH], occurring in 
colorless, crystalline needles with an 
acidulous taste, soluble in 100 parts 
of water, and freely soluble in alcohol. 
Salicylic acid is liberated from it in 
the intestine. It causes less sweat- 
ing than the ordinary salicylates. 
Dose, 5 to 30 grains (0.3 to 2 Gm.). 

Diaspirin (succinic ester of salicyl- 
ic acid) [CoH4(COO.C6H4COOH)2], 
a white powder with slightly acid 
taste, sparingly soluble in water, 
easily soluble in alcohol. Dose, 5 to 
30 grains (0.3 to 2 Gm.). Stronger 
than novaspirin, but has marked 
sudorific power (Klaveness). 

Novaspirin (methylene citrylsali- 
cylic acid), a white, crystalline pow- 
der with a faint acidulous taste, 
scarcely soluble in water, freely solu- 
ble in alcohol. Contains 62 per cent, 
of salicylic acid. Dose, 10 to 30 
grains 0.6 to 2 Gm.). Weaker in 



4S SALICYLIC ACID, THE SALICYLATES, AXl) SALICIN (SAJOUS). 



action than the preceding-, though bet- 
ter tolerated l)y sensitive patients. 

Salicylosalicylic acid (diplosal ; 
salicylic ester of salicylic acid) [Cq- 
H4(COO)OH.COOH.CcH4], a color- 
less, tasteless powder, almost insolu- 
ble in water, readily soluble in dilute 
alkalies. It yields 1.07 times as much 
jf the salicyl group in the organism 
as salicylic acid itself, owing to the 
fact that in its molecule two mole- 
cules of salicylic acid are present in 
condensed form, one molecule of 
water (HoO) having been eliminated. 
It is unirritating to the stomach and 
is absorbed from the intestine. Dose, 
5 to 20 grains (0.3 to 1.3 Gm.). 

Antipyrin salicylate (salipyrin) 
[CiiHioNoO.CcHiOH.COOH], a 
white, crystalline powder, slightly 
sweetish, soluble in 200 parts of w^ater, 
readily soluble in alcohol. Acids 
liberate salicylic acid from it, and 
alkalies, antipyrin. Dose, 5 to 15 
grains (0.3 to 1 Gm.). 

Ferric salicylate (iron salicylate) 
[Feo(OOC(OH)C6H4)3], a reddish- 
brown or violet-gray powder, spar- 
ingly soluble in water, readily soluble 
in a solution of potassium bicarbonate. 
Dose, 3 to 10 grains (0.2 to 0.6 Gm.). 

Guaiacol salicylate (guaiacyl salicy- 
late; guaiacol-salol) [C6H4.OH.COO- 
(C6H4.OCH3)], a white, crystalline, 
tasteless powder, insoluble in water, 
soluble in alcohol. Decomposed by 
alkalies. Analogous to phenyl sali- 
cylate (salol). Dose, 5 to 15 grains 
(0.3 to 1 Gm.). 

Naphthol salicylate (betol ; naph- 
thalol ; betanaphthyl salicylate ; naph- 
thol-salol) [C6H4-OH.COO(CioH7)], 
a white, shining, tasteless, crystalline 
powder insoluble in water, with diffi- 
culty solube in alcohol. Decomposed 
when treated with alkalies. Split up 



in the intestine by the pancreatic juice 
and intestinal secretions. Dose, 4 to 
8 grains (0.25 to 0.5 Gm.). 

Quinine salicylate (saloquinine ; 
salicyl quinine), a white, crystalline 
powder, tasteless, insoluble in water, 
moderately soluble in alcohol, and 
containing 73.1 per cent, of quinine. 
Dose, 5 to 30 grains (0.3 to 2 Gm.). 

Santalol salicylate (santyl ; santalyl 
salicylate), a yellowish oil with faint 
balsamic odor and taste, soluble in 
about 10 parts of alcohol. Split up in 
the intestines, yielding 60 per cent, of 
santalol (santal oil). Dose, 8 minims 
(0.5 c.c). 

Unofficial salicylic preparations 
used externally : Ethyl salicylate (sal 
ethyl) [C0H4.OH.c6o.C2H5], a col- 
orless, volatile fluid with a pleasant 
odor and taste, insoluble in water, 
soluble in alcohol. Analogous to 
methyl salicylate. ]\Iay be used both 
externallv and internallv. 

Mesotan (methyl-oxymethyl salicy- 
late; ericin) [C6H4.0H.Cob(CH2.- 
O.CH3)], a yellowish, faintly aro- 
matic^ oily fluid, but little soluble in 
water, soluble in alcohol, miscible 
with oils. To be applied, diluted 
with an equal volume of olive oil, to 
the skin, avoiding friction, as meso- 
tan is somewhat irritating. 

Salophen ' (acet3'lparamidophenol 
salicylate), a white, tasteless, crystal- 
line powder, almost insoluble in cold 
water, freely soluble in alkaline solu- 
tions, and in alcohol. It contains 51 
per cent, of salicylic acid. It is broken 
up in the intestine, liberating salicylic 
acid, and acetylparamidophenol. 
Dose, 5 to 20 grains (0.3 to 1.3 Gm.). 
Used externally in a 10 per cent, oint- 
ment in itching skin affections. 

Spirosal (monoglycol salicylate) 
[C6H4.0H.COO(CH2.CH2.0H)], an 



SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 49 

oily, almost odorless fluid, soluble in tation, and an appropriate amount 
about 110 parts of water, freely solu- ordered mixed with some sparkling 
ble in alcohol. To be applied to the water at each dose. An effervescent 
skin undiluted, mixed with 3 parts of preparation may be secured by pre- 
alcohol or 8 parts of olive oil, or in scribed equal amounts of salicylic 
a 50 per cent, petrolatum ointment, acid and sodium bicarbonate in pow- 
It is absorbed through the skin with- ders, to be dissolved in water and 
out irritation and sets free salicylic taken when the effervescence begins 
acid in the tissues. to subside. Small doses of sodium 
INCOMPATIBILITIES.— Salicy- salicylate may be given in capsules, 
lates are incompatible with mineral to be taken only during or after 
acids, which set free the relatively meals. Strontium salicylate is pre- 
insoluble salicylic acid by combining ferred by some to the sodium salt, 
with the basic element. They are Oil of gaultheria (wintergreen) or 
also incompatible with sweet spirit of methyl salicylate may also be sub- 
niter, with lime-water, and with qui- stituted for it, given in elastic cap- 
nine salts, ferric salts, lead acetate, sules during or after meals, 
and silver nitrate in solution, as well The co-operative investigation of 
as with sodium phosphate in powder the eft'ects of synthetic sodium sali- 
form. Mixtures of quinine and cylate and sodium salicylate prepared 
acetylsalicylic acid are dangerous, de- from natural sources, reported by 
veloping after a time the poisonous Hewlett, and based on about 230 sep- 
substance quinotoxin, which resem- arate observations, showed that, from 
bles digitoxin in its action. This toxic the clinical standpoint there is no 
change develops even more readily in essential difference between the two 
a mixture of cinchona and acetyl- varieties of the drug. According to 
salicylic acid, and also in elixirs and Pulliam, gastric irritation by sodium 
syrups containing quinine in acid salicylate may be due to deteriora- 
solution. tion, moisture gradually decomposing 
MODES OF ADMINISTRATION, the salt with liberation of sodium hy- 
— Salicylic acid, which is irritating to droxide and salicylic acid, 
mucous surfaces, should always be Where sodium salicylate given as 
given in solution, preferably with above described is badly tolerated by 
potassium citrate or acetate, or am- the patient, resort may be had to such 
monium acetate or phosphate, all of preparations as acetylsalicylic acid, 
which increase its solubility in water, salophen, diaspirin, and novaspirin, 
Or, it may be given in a syrup, which liberate the salicyl group only 
flavored with compound spirit of in the intestine (and therefore have 
lavender, or in elixir of orange. Pref- the disadvantage of acting more 
arable to the acid, however, is sodium slowly and often less powerfully), 
salicylate, which, though less irritat- or to salicin, given in generous dos- 
ing, should likewise be given in solu- age. Or, the cutaneous, rectal, hypo- 
tion. The salt may, for example, be dermic, or intravenous routes of ad- 
prcscribed in 5 parts of Aqua men- ministration may be partly or wholly 
thae piperitae or Aqua gaultherise, with relied on. 
a little glycerin added to reduce irri- For application to rheumatic joints 

8-4 



50 SALICYLIC ACID, THE SALICYLATES, AND SALICLM (SAJOUS). 

methyl salicylate or oil of gaultheria after it acts by the salicylate enema, 

is generally used, either undiluted, on g'^'^'" ^ith the Davidson syringe and 

, ^ 1 . ^. 1 I 1 • • „„ii a rectal tube inserted 6 to 8 inches, 

absorl^ent cotton or rubi)ed ni ni small .r^, , • • , , 

i no dose varies with the weight and 

amounts, or diluted with an equal part ,,^ .„,^, t,,^ severity of the case. The 

of olive oil or 2 or more parts of first adult dose in men is usually from 

petrolatum, chloroform liniment, or 8 to 10 Gm. (2 to 2>4 drams), in women 

soap liniment. To prevent evapora- 6 Gm. {\y, drams). The drug to be 

.■ r ,1 -1 -1 1 -11 .„ given is incorporated in 120 to 180 

tion of the oils, oiled silk or some ,, . . ^ , . 

. . . c.c. (4 to 6 ounces) of plain or starch 

otiier impervious covering may be ^^^^^^ ^^-^^^ the addition of 1 to L5 

used. Where these oils are not at Gm. (15 to 23 ounces) of opium tine- 
hand, absorption of salicylic acid it- ture. The dose may be repeated 
self may be secured bv rubbing in for within twelve hours, but usually a 
a few minutes a tal^lespoonful of a daily enema suffices, with doses in- 
. , . , . , . _ creasing perhaps from 30 to 50 per 
mixture of 1 part of the acid m b ^^^^ j^j,y ^^^jj ^^e limit of tolerance 

parts of alcohol and 10 parts of cas- is reached. The largest daily dose 

tor oil (Cullen), or an ointment com- given was 24 Gm. (6 drams). The 

posed of salicylic acid and oil of o"ly symptoms of salicylism usually 

turpentine, of each 1 part, and hy- appearing were tinnitus and exces- 

, , , r o ^T-. 1 N sive perspiration. The ready absorp- 

drated wool-fat, 8 parts (Bracken). ,. u u ^ t ■ 

^ i- \ ' tion was shown by a strong ferric 

The efficiency of either of these chloride reaction in the urine within 

methods is shown by the disappear- thirty minutes. It would seem that 

ance of joint pain and appearance of the greatest absorption of the drug 

the drug in the urine within a few ^^ ^'^^hin twelve hours. L. G. Heyn 

r^^-, ,1 c ^^ (Tour. Amer. Med. Assoc, Sept. 19, 

minutes. Other local uses of sail- ,g. . 

cylates are described in the section on 

Therapeutics '^^^ hypodermic and intravenous 

For rectal administration of sodium ^^^^^^ ^^^^'^ '^^e" ^^'^'^^^ o^' ^""'^^ §^oo^ 
salicylate the following formula, ''^^^^t^' ^^^ ^^^^ert and by Mendel, 
recommended by Crouzet, may be Rubens, and Conner, respectively, 

employed : Intravenous injection of salicylates 

■D c J-- T 1 J- .% /le /" \ strongly recommended. The prep- 

-r> Sodii sahcylafis 5ss (15 Gm.). . , . 

A •,,;„• 7- //( r- ^ aration used consists of: — 

Acacia piilveris 3j (4 Gm.). 

Lactis fSiv (120 Gm.). Sodium salicylate 2 dr. (8 Gm.) 

Fiat mistura. Caffeine sodiosalicyl.. . Yi dr. (2 Gm.). 

T-i . ^ , ' 'its ' Sterile water 1^ oz. (45 c.c). 

1 he mixture contains 30 grains 

(2 Gm.) of sodium salicylate to the One-half dram (2 c.c) is injected 

tablespoonful, is well tolerated, and *^.^*=^ ^ f'^- /' ^^l '"'"^^' J°^"* 

, . , ,-7 • 1- pains and exudates disappear even 

can be given ad libitum, according to , j- r i * ^ 4. ^ 

o ' ^ where ordinary salicylate treatment 

the requirements of the case, with a f^iis. a single dose causes marked 
glass syringe or the ordinary rubber improvement. None of the unpleas- 
enema bulb. ant actions of salicylates are en- 
Intrarectal administration of so- countered. Cases which do not react 
dium salicylate recommended in re- are not rheumatic. This is the most 
fractory cases of acute and subacute certain method of diagnosing the ex- 
rheumatism from experience in 125 act nature of doubtful rheumatic 
cases. A cleansing soapsuds enema cases, especially in diagnosing early 
is given and followed immediately tuberculous and rheumatoid arthritis 



SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 



51 



from true rheumatic cases. F. Men- 
del (Miinch. med. Woch., p. 165, 
1905). 

The writer injects 10 c.c. (2J^ 
drams) of a 20 per cent, sterilized 
solution of sodium salicylate per 100 
pounds of body weight for acute 
rheumatic infections of joints, heart, 
pericardium and pleura. He first uses 
a hypodermic injection of cocaine 
and fifteen minutes later injects in the 
same spot the sodium salicylate. The 
dose is repeated every twelve hours. 
In severe cases with multiple lesions 
15 c.c. (4 drams) to each 100 pounds 
of body weight is advised. Within 
three hours after the first injection, 
pain, fever, joint stiffness and pulse 
rate diminish. This improvement 
continues if the injections are re- 
peated every twelve hours, but if 
omitted the conditions grow worse. 

In chronic cases, 10 c.c. (2^ drams) 
per 100 pounds of body weight of the 
following oily solution are injected 
every twenty-four hours: Salicylic 
acid, 10 Gm. (2>^ drams) ; sesame oil, 
80 Gm. (2% ounces) ; pure alcohol, 5 
Gm. (l]4 drams); and gum camphor, 
5 Gm. (1j4 drams). This is sterilized 
before the alcohol is added. It must 
not be exposed to the air, as the 
alcohol will evaporate and the sali- 
cylic acid precipitate. The effect in 
chronic cases is more rapid when 
multiple localizations of the rheu- 
matic process exist than when one 
joint is affected. In the former, pain 
and stiffness usually improve after 
the first injection; in the latter, after 
the third. Addition of camphor (5 
to 20 per cent.) was found beneficial 
in stimulating the heart when the 
pericardium or endocardium was in- 
volved. With this method there is 
entire absence of the toxic symptoms 
seen when salicylates are given by 
mouth. Siebert (Med. Rec, Mar. 11, 
1911). 

The rapidity of absorption of 
sodium salicylate when given sub- 
cutaneously is about the same as by 
other routes, but its concentration in 
the blood does not reach one-half of 



that when it is given intramuscularly. 
Sodium salicylate disappears from 
the blood in ten hours when given 
subcutaneously; if given per os it is 
present in the blood after twenty- 
four hours. E. Levin (Dent. med. 
Woch., Dec. 19, 1912). 

Administration of sodium sali- 
cylate by intravenous injections is 
safe, painless, and easily performed. 
The drug seems to have a much more 
pronounced analgesic effect than 
when givent by mouth. The solution 
for injection is made by dissolving 
10 Gm. (2^ drams) of chemically 
pure crystalline sodiuin salicylate in 
50 c.c. (1% ounces) of distilled water, 
freshly sterilized by boiling. In most 
cases the dose has been either 15 or 
20 grains (1 or 1.3 Gm.) and the in- 
jections given at twelve- or eight- 
hour intervals over a period of three 
to six days. Occasionally, in robust 
men, as much as 30 grains (2 Gm.) 
have been given at a time, and as 
much as 120 grains (8 Gm.) given in 
the first twenty-four hours without 
any unpleasant effects. The field of 
indication for the intravenous method 
includes cases in which the drug is 
not well borne by the stomach; those 
which show little or no improvement 
under the usual methods and, pos- 
sibly, cases of severe rheumatic in- 
flammation of the eye. Conner (Med. 
Record, Ixxxv, 323, 1914). 

Case of a man of 25 with extremely 
severe febrile rheumatism involving 
all the joints, with mj'^ocarditis and 
dyspnea; the stomach being abso- 
lutely intolerant for the salicylates. 
The writer gave an intravenous in- 
jection of 6 c.c. (1^ drams) of a 
mixture of 5 Gm. (1^4 drams) sodium 
salicylate and 0.25 Gm. (4 grains) 
caffeine in 25 Gm. (6 drams) distilled 
water. The injection was repeated 
daily for six days, increasing the 
amount from 1.2 to 2 Gm. (20 to 32 
minims). By the fourth day the man 
was able to sit up, with normal tem- 
perature, pulse 84, and no further 
precordial distress. Cernadas (Se- 
mana Medica, Dec. 23, 1915). 



52 SALICYLIC ACID, THE SALICYLATES, AND SALICIX (SAJOUS). 



Phenyl salicylate (salol), in its 
usual dosage of 5 or 7^ grains (0.3 
or 0.5 Gm.) every three or four hours, 
exerts but little of the effect of sali- 
cylates and rather acts like phenol, 
which it gives ofif in the intestinal 
tract. Large doses of phenyl sali- 
cylate are, as a rule, to be avoided, 
as they may induce symptoms of 
phenol poisoning, and darken the 
urine. It may be given in capsules, 
in taljlets, or combined, for example, 
with bismuth salts, in powders. It is 
almost insoluble in the gastric juice, 
and does not irritate the stomach. 

CONTRAINDICATIONS. — Sali- 
cylates are contraindicated except 
sometimes when used for local pur- 
poses, in middle-ear disease, and in 
conditions associated with impaired 
renal functioning, as in pregnancy 
and chronic nephritis. Albuminuria 
is a contraindication, except in renal 
disturbance of rheumatic origin, 
though in infections of the urinary 
tract phen)^ salicylate is used. Sali- 
cylates should not be administered to 
pregnant women who have a tend- 
ency to abort, nor in women with 
metrorrhagia or menorrhagia. Where 
there is circulatory depression, some 
degree of caution as to the dosage of 
salicylates is required. 

Prolonged administration of sali- 
cylates in large dosage is unwise, 
causing debility, anemia, and a ten- 
dency to hemorrhage from the mu- 
cous membranes. 

PHYSIOLOGICAL ACTION.— 
Externally, salicylic acid is an irritant, 
especially to mucous membranes. 
Carefully applied to the skin it is 
capable of softening the epidermis or 
accumulations of horny epithelium 
without inducing inflammation. It 
also tends to arrest local sweating 



and to promote the growth of normal 
skin in chronic skin affections. It is 
an antiseptic, stronger than acetani- 
]ide and rivalling phenol, over which 
it has the advantage of not volatiliz- 
ing. The salts of salicylic acid are 
less irritating than the free acid, and 
also much less strongly antiseptic. 
The liquid salicylates, such as methyl 
salicylate and the oils of wintergreen 
and birch, are, however, useful as 
counterirritants. 

General Effects. — Nervous System. 
— The chief nervous effects of sali- 
cylates is manifest in relief from pain, 
probably due, as in the case of 
acetanilide and its congeners, either 
to constriction of vessels loco doleiiti 
or to direct depression of the sensory 
nerve-cells in the optic thalami. 

Circulation. — Small doses, if any- 
thing, slightly raise the blood-pres- 
sure (chiefly by central vasoconstric- 
tion) and accelerate the heart. 
Large doses directly depress the 
heart. The skin-vessels are dilated 
by all doses. According to some the 
number of leucocytes in the blood 
shows a marked increase, returning 
to normal, however, after a single 
dose, within two hours. 

Alimentary Tract.— ^Idiny of the 
salicylates, especially the free acid, 
act as irritants in the stomach. 
Acetylsalicylic acid, phenyl salicylate 
(salol) and salicin, however, may not. 
passing through the stomach un- 
changed and only setting free the 
salicyl group in the intestine. Sali- 
cylic acid tends to arrest ferment 
action, interfering, therefore, with the 
digestive processes. It is claimed 
that intestinal putrefaction can be re- 
duced with it, and, according to some, 
large doses of salicylates stimulate 
the formation of bile. 



SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 53 



Temperature. — Salicylates lower the 
temperature where there is fever, like 
antipyrin, but act less strongly. The 
effect is, at least in part, due to pe- 
ripheral vasodilatation and sweating, 
which increase heat loss. A direct 
action on the heat centers has not as 
yet been proved to occur. 

Metabolism. — Augmented destruc- 
tion of protein is caused by the sali- 
cylates, as shown by a distinct in- 
crease in the output of urea, uric acid, 
and sulphur-bearing compounds in 
the urine. 

The increased output of uric acid 
following salicylate medication is 
due to a lowered threshold value of 
the kidney, not only for uric acid, 
but in all probability for other waste 
products as well. Such being the 
case, it may well be that the bene- 
ficial effects resulting from the use 
of salicylates in acute rheumatic 
fever may, in part at least, be due to 
a power possessed by this class of 
drugs of increasing kidney permea- 
bility, thereby facilitating the rapid 
and more or less complete excretion 
of the toxins which produce symp- 
toms of these diseases. Denis (Jour. 
Pharmacol, and Exper. Therap., Oct., 
1915). 

Absorption and Elimination. — Sali- 
cylates are rapidly absorbed from the 
stomach and duodenum, and circulate 
in the blood as salicylates of the alka- 
lies. Excretion is also rather rapid, 
and takes place chiefly through the 
kidneys, which are irritated by large 
doses and sometimes react, even after 
moderate doses, by a diuresis. The 
chief product in salicylic elimination 
has long been considered to be salicyl- 
uric acid, an inert compound with gly- 
cocoll yielding a violet-red color with 
ferric chloride. Studies by Hanzlik 
(191.S), however, cast doubt upon the 
elimination of salicyluric acid in man, 
products free of glycocol), and pre- 



sumed to be in part an impure sali- 
cylic acid, being alone found. Small 
amounts of salicylates ingested are 
eliminated with the bile, sweat, and 
mammary secretion. 

UNTOWARD EFFECTS AND 
POISONING. — Overdoses of salicylic 
preparations produce symptoms simu- 
lating cinchonism, viz., a feeling of 
fullness in the head, tinnitus aurium 
and, perhaps, slight dizziness. Other 
signs of overdosage are gastric irri- 
tability, nausea and vomiting; head- 
ache ; inental dullness and apathy, and 
impairment of hearing or vision, due 
either to local circulatory modifica- 
tions or to degenerative changes in- 
duced in the cochlear or retinal nerve- 
cells or in the optic nerve. After very 
large doses complete deafness or 
blindness may occur. According to 
Drayer, 15 grains (1 Gm.) 4 times a 
day for a week will often produce 
deafness lasting four months. 

In some cases of salicylism, mental 
excitation is a feature — the "salicylic 
jag." The cerebral symptoms are 
similar to those induced by atropine, 
— talkativeness and great cheerfulness 
passing on to delirium with halluci- 
nations and motor restlessness. De- 
lirium is an especially common symp- 
tom among drunkards. Mental dis- 
turbance may persist a week or more. 
A number of patients taking sali- 
cylates experienced auditory hallu- 
cinations. Long- forgotten memories of 
certain sounds were aroused : the roar 
of a certain water-fall, the singing of 
birds heard in a certain garden, etc. 
The drug reaching the cells seemed to 
bridge the gap between unconscious 
and conscious memories. Seitz (Corre- 
spondenzbl. f. schweizer Aerzte, Apr. 
1, 1909). 

Poisonous doses of salicylic acid 
induce l)urnin-- in the throat, nausea 



54 SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 



and vomiting, sometimes diarrhea; 
special sense disturbances, sometimes 
with mydriasis, ptosis, or stralMsmus ; 
thirst; precordial oppression; feeble 
heart action and vasomotor weakness; 
sweating; marked dyspnea; prostra- 
tion ; greenish urine, and occasionally 
albuminuria, hematuria, or even sup- 
pression of urine ; coma. Death, when 
it occurs, is due to respiratory paraly- 
sis, and may be preceded by general 
convulsions. 

A girl, aged 10 years, had been suf- 
fering from acute rheumatism for 
three days. Endocarditis developed. 
A purgative was given and then IS 
grains (1 Gm.) of sodium salicylate 
with double that amount of sodium 
bicarbonate every four hours, for 
four days, when the child became 
delirious and vomited twice. The 
salicylate was withdrawn and the de- 
lirium quickly passed ofif. On the 
fourth day after admission the tem- 
perature, pulse, and respirations were 
normal. 

Later, the patient again complained 
of joint pains and salicylates were re- 
sumed (7 grains — 0.45 Gm. — in water 
3 times a day). After two days she 
again vomited. There was no deliri- 
um, but the urine contained sufficient 
blood to give it a deep-red color. She 
also complained of severe pain along 
the left iliac crest, and there was 
much tenderness in the left renal re- 
gion. Salicylates being discontinued, 
the urine was clear in four days, con- 
taining neither blood nor albumin, 
and the pain had also disappeared. 
The pain was probably a "referred 
pain" from the kidney. J. D. Mar- 
shall (Lancet, Feb. 2, 1907). 

The dosage of salicylic preparations 
necessary to induce circulatory de- 
pression is relatively large, 20 grains 
of sodium salicylate, repeated at inter- 
vals of two or three hours, rarely 
having an appreciable action on the 
pulse and blood-pressure. 



The primary effect of salicylates is 
on the temperature, which drops sud- 
denly owing to increased heat radia- 
tion through the dilated capillaries. 
The resulting depression of the nerv- 
ous system determines the collapse. 
These drugs should be given in small 
doses, frequently repeated, to avoid 
rapid temperature reduction. Bovisoff 
(Roussky Vratch, Feb. 23, 1913). 

Experiments showing that solu- 
tions of sodium salicylate gradually 
deteriorate on standing, the loss be- 
ing greater in the weaker solutions. 
About 20 per cent, is destroyed in the 
body, and 40 per cent, when there is 
fever, alcoholism, morphinism, or 
exophthalmic goiter. Hanzlick and 
Wetzel (Jour, of Pharm. and Ex- 
perim. Therap., Sept., 1919). 

Erythema with edema, intolerable 
itching and tingling of the skin, and 
fever, have been catised by large doses 
of sodium salicylate. Other possible 
effects are transitory dark-colored 
spots, ecchymoses, vesicles and pus- 
tules. 

According to Martinet, sodium sali- 
cylate sometimes induces in children 
symptoms similar to those of diabetic 
acidosis. Sodium bicarbonate in large 
doses and catharsis are advocated in 
the treatment. 

A chronic form of salicylic poison- 
ing has been met with in persons ex- 
posed to inhalation of the acid, 
marked by a subacute inflammation 
of the air-passages, sometimes with a 
serious degree edema. In these in- 
stances potassium iodide is beneficial. 
Chronic absorption from food or drink 
preserved with salicylic acid may re- 
sult in constipation alternating with 
diarrhea, mental depression, skin 
eruptions, and albuminuria. 

TREATMENT OF POISONING. 
— The tinnitus caused by salicylic 
acid may be relieved by a 20-grain 
(1.3 Gm.) dose of sodium bromide. In 



SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 55 



the treatment of salicylism, the giving 
of large doses of sodium bicarbonate 
has been recommended to hasten 
elimination of the drug. The treat- 
ment of severe acute poisoning is 
largely symptomatic, cracked ice by 
the mouth and an ice-bag or mustard 
plaster over the epigastrium being 
used to relieve vomiting, cold com- 
presses being applied for headache, 
veronal or opiates given for the rest- 
lessness and delirium, and appropri- 
ate stimulants for circulatory depres- 
sion. As in other forms of acute 
poisoning the stomach should be 
thoroughly evacuated with the 
stomach-tube or emetics and, if it 
seems advisable, a purge given to 
clear the drug from the intestine. For 
further suggestions as to treatment 
the reader is referred to the sections 
on Poisoning in the articles on Ace- 

TANILIDE, ACETPHENETIDIN, and AnTI- 
PYRIN. 

THERAPEUTICS.— Salicylic acid 
and its salts are used for both general 
and local effects. 

General Uses. — As remedies in 
acute rheumatism, the salicylates 
hold first rank by reason of the 
prompt relief of pain, fever and other 
symptoms of this disease they afford. 
Various methods of administration 
have been suggested, some of which 
are referred to in the article on Rheu- 
matic Fever. Plehn, among others, 
lays stress on adequacy of dosage, 
giving even mild cases 15 grains (1 
Gm.) of salicylic acid 6 times a day 
(suspending the remedy at night), 
until the temperature has remained 
normal for three days, after which a 
few 15-grain (1 Gm.) doses are given 
daily for a week, the patient then re- 
maining in bed three days more, with- 
out the remedy. In women the dos- 



age is made smaller — often only 5 and 
sometimes only 3 doses a day at the 
outset. With this treatment, Plehn 
observed the development of valvular 
disease in only 2 out of 319 cases 
treated. Plehn's dosage, however, 
seems somewhat excessive from the 
standpoint of special sense impair- 
ment and renal irritation. Sodium 
salicylate is better tolerated by the 
stomach than the free acid and may 
be substituted for it for this reason. 
Tinnitus should be regarded as a 
warning signal against large dosag-e. 
Homberger advises the combination 
of sodium bicarbonate (1 or 2 parts) 
with sodium salicylate, given in solu- 
tion in a little water, the purpose 
being to prevent liberation of the 
more irritating salicylic acid from the 
salicylate by the hydrochloric acid of 
the gastric juice, and simultaneously 
to accelerate absorption of the sali- 
cylate by means of the carbon-dioxide 
gas evolved. He al&o advises that the 
drug be given between meals, when 
there is least acid in the stomach, and 
not too freely diluted, as a large quan- 
tity of fluid will cause it to be retained 
longer in the stomach. Salicylic 
treatment in those with sensitive 
stomachs can likewise be carried out 
with acetylsalicylic acid (aspirin), 
which sets free the salicyl group only 
in the intestinal alkaline medium. 
Klaveness prescribes this drug in 15- 
grain (1 Gm.) doses every two or 
three hours, combined, in persons in 
whom circulatory weakness is sus- 
pected, with V/2 grains (0.1 Gm.) of 
powdered ergot. In children. Osier 
is credited with recommending sali- 
cin in full doses; Comby praises the 
action of sodium salicylate in the dos- 
age of 7 grains (0.5 Gm.) a day for 
each year of the child's age. The 



56 SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 



rectal, intravenous, intramusclar, and 
percutaneous methods of administer- 
ing salicylates are also available. 

Renal irritation from salicylates, 
manifested in slight albuminuria, 
sometimes with a few casts, is gen- 
erally recognized to be a temporary 
condition, though it may persist for 
weeks and even be serious where 
some degree of nephritis already ex- 
ists. .Combination with sodium bicar- 
bonate was found by Glaesgen to 
obviate renal irritation by the salicy- 
lates. Acetylsalicylic acid is held 
by some to be non-irritating to the 
kidneys. 

In muscular rheumatism, including 
lumbago, the salicylates are of value 
in relieving the pain ; likewise in the 
so-called "growing pains." In gonor- 
rheal rheumatism their effect is less 
marked. The pains of chronic fibro- 
sitis are quickly relieved by sodium 
salicylate combined with antipyrin 
(Stark). In sciatica and other painful 
rheumatic nervous conditions the sali- 
cylates are also of distinct value. In 
migraine, a combination of sodium 
salicylate and potassium bromide, 
given at the start of the attack, often 
yields a gratifying result. In rheu- 
matic uveitis and scleritis marked 
benefit is obtained from 15-grain (1 
Gm.) doses of the salicylates, given 
4 times a day. 

In rheumatic conditions associated 
with anemia the writer uses the fol- 
lowing mixture: In an 8-ounce (240 
c.c.) bottle place 1 dram (4 Gm.) of 
sodium salicylate and dissolve it in 
about 2 ounces (60 c.c.) of water. Add 
liquor ferri perchloridi (B. P.) Y2 
dram (2 c.c), plus about an ounce 
(30 c.c.) of water. This produces a 
dark-purple mixture with a thick, 
curdy precipitate. Then add 1 dram 
(4 Gm.) of potassium bicarbonate 
dissolved in 1 ounce (30 c.c.) of water, 



and fill up the bottle to 8 ounces (240 
c.c.) with water. The precipitate dis- 
solves on the addition of the potas- 
sium solution, and the result is a clear 
claret-colored mixture of an agree- 
able taste. 

The mixture was found particularly 
useful in a kind of sore throat ap- 
parently of rheumatic origin (primary 
or secondary) with slight redness and 
pain, especially on swallowing. H. 
Drinkwater (Liverpool Medico-Chir. 
Jour., July, 1911). 

For the relief of pain in general, the 
acetyl preparations of salicylic acid, 
such as aspirin and diaspirin, seem 
more efficient than the other prepara- 
tions. In neuralgia, the pains of tabes 
dorsalis, and those of peripheral neuri- 
tis, these drugs often prove of value. 
In mild forms of dysmenorrhea, 
acetylsalicylic acid is a particularly 
efficient remedy. It may also be used 
in acute and subacute pelvic cellulitis, 
salpingitis, ovaritis, and parametritis. 

In acute tonsillitis or peritonsillitis, 
frequently rheumatic in nature, sali- 
cylates are considered of value, re- 
lieving pain and swelling, shortening 
the period of illness, and perhaps 
obviating suppuration if given early. 
In addition to its internal use, garg- 
ling with, c. g., lyi io2 drams (6 to 8 
Gm.) of sodium salicylate in 6 fluid- 
ounces (180 c.c.) of peppermint-water 
(Cheveller), or direct application of a 
salicylate to the tonsils (Fetterolf), 
has been advised. 

Salicylate of iron recommended in 
erysipelas and acute tonsillitis. Care 
should be taken in its preparation, 
that the iron is added to the sodium 
salicylate, otherwise the characteris- 
tic reddish-brown precipitate does not 
form. 

For adults, the dose generally con- 
tains 7H grains (0.5 Gm.) of sodium 
salicylate and potassium bicarbonate, 
and 7^ minims (0.45 c.c.) of the B. 
P. liquor ferri perchlor. The solution 



SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 57 



is of a clear violet color, and is quite 
palatable, though it may be sweet- 
ened if necessary. It is non-depres- 
sant, non-constipating, and is a well- 
marked febrifuge. The feces are 
colored black. 

In erysipelas the mixture acts with 
the greatest rapidity, cutting short 
the disease, which never lasts more 
than 10 days, and in most cases is 
cured in 3 or 4. After the first few 
doses, there is a striking alleviation 
of all pain. The drug is administered 
every three hours, the treatment be- 
ing commenced with a purgative, such 
as calomel. As a rule, within 24 
hours the temperature is normal, the 
disease has ceased to spread, and the 
patient feels better. 

The cases of acute tonsillitis in 
which salicylate of iron has an ex- 
cellent action are probably those of 
streptococcal origin. It acts very 
quickly; if, after 3 days, there is no 
marked improvement, it is not worth 
while continuing. In a recent out- 
break of sore throats at a school, the 
drug was markedly successful in 
about 50 per cent, of cases. 

In cases of erysipelas of great 
severity, the writer often adds twice 
the usual amount of iron, which pro- 
duces a very dark solution but no 
precipitate, and is much stronger in 
its action on the disease. M. C. S. 
Lawrance (Practitioner, Mar., 1913). 

In influenza or grippe, Stark admin- 
isters the following after a mercurial 
purge :— 

R Sodii salicylatis. 
Potass a hicarbona- 

t'ls aa gr. X (0.6 Gm.) . 

Tiiictitrtc inicis vom- 
ica: TTL X (0.6 c.c.) . 

Aq. chlorof. ..q. s. ad fSj (30 c.c). 

M. Sig. : Every two to four hours. 

Good results in pneumonia of in- 
fluenzal origin, in that succeeding 
measles, and in pharyngitis, laryn- 
gitis, and bronchitis, Ijy bical applica- 
tion of a 10 per cent, solution of sal- 
icylic acid and of castor oil, respec- 
tively, in 90 per cent, alcohol. In the 



pneumonic cases a compress moist- 
ened with the solution was placed over 
the entire back, covered with imper- 
meable material, and held in place by 
a bandage. The dressing was renewed 
whenever it became dry. A prompt 
and very favorable influence upon the 
cough, temperature, pulse and res- 
piration was noted. L. G. Boutchin- 
skaia-Yourchevskaia (Semaine med., 
Sept. 11, 1912). 

In acute coryza, the same author 
recommends the following : — 

R. Sodii salicylatis gr. x (0.6 Gm.). 

Spiritus amnioiiicc aro- 

matici f3ss (2 c.c). 

Tincturcc belladonmr 

foliorum m. v (0.3 c.c.) . 

Aq. chlorof. ..q. s. ad f5j (30 c.c). 
M. Sig. : Every four hours. 

Stark has also found the drug use- 
ful in mumps, in puerperal fever, and 
in "bilious headache," in the latter 
condition combined with potassium 
bromide. 

In gout, salicylic acid, though in- 
ferior to colchictim, may be of value 
for a short time. It was found by 
Fine and Chace (1915), to increase 
the elimination of uric acid, some- 
times even more than atophan. In 
phosphaturia, sodium salicylate will 
clear up the urine and arrest the reflex 
nerve pains. 

In pleural effusion, 30 to 60 grains 
(2 to 4 Gm.) of sodium salicylate are 
credited with some power to promote 
absorption of the effusion. 

In diabetes mellitus, von Noorden 
considers sodium salicylate the most 
useful of the drugs, with the excep- 
tion of codeine and other nerve 
sedatives. 

Chibret found sodium salicylate in 
a daily dosage of 1 dram (4 Gm.) of 
some value in l)ringing symptomatic 
relief in exophthalmic goiter. Monae- 
Lesser observed that the administra- 



58 SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 



tion of 3 or 4 15-i^rain (1 Gm.) doses 
of sodium salicylate in renal and hep- 
atic colic assisted the action of opiates 
and, by relaxing the channels, favored 
passage of the stones. The same 
author advises the giving of sodium 
salicylate by the mouth or rectum (15 
grains every three hours) in cystitis 
and acute prostatitis, and treats acute 
ascending cellulitis of the extremi- 
ties by administering this salt intern- 
ally and applying locally an ointment 
consisting of magnesium carbonate, 
resorcinol, and lanum. 

The value of phenyl salicylate 
(salol) as an antiseptic acting in the 
urinary passages is well known. A 
dosage exceeding 30 grains (2 Gm.) 
a day is rarely necessary, and is, in 
fact, likely to produce untoward re- 
sults. The drug should, therefore, 
ordinarily not be employed in acute 
rheumatism. It is of value, however, 
in gonococcal urethritis, in pyelitis, 
and in certain forms of cystitis. 

For purposes of intestinal antisep- 
sis, phenyl salicylate is likewise the 
most useful drug of this group, hav- 
ing the added advantage of not up- 
setting the stomach. Diarrhea due to 
an acute infection or toxic food is 
frequently arrested by phenyl salicy- 
late, which may be given alone in 5- 
or yyz- grain (0.3 to 0.5 Gm.) doses in 
capsules or tablets or with 2 or 3 
parts of bismuth subnitrate in pow- 
ders. Bismuth subsalicylate may be 
substituted for the last-named com- 
bination, but its antiseptic effect is 
far inferior, ownng to the absence of 
phenol. 

Local Uses. — In subacute and 
chronic eczema, salicylic acid often 
gives excellent results, more particu- 
larly in the "rubrum" and squamous 
varieties, or where there is consider- 



able Assuring, e.g., on the dorsa of the 
liands and in the flexures of the joints. 
An ointment containing 4 to 8 per 
cent, of salicylic acid in either petrola- 
tum, hydrated wool-fat, or zinc-oxide 
ointment should be used in such cases. 
In eczema of the face, in the weeping 
stage, or in not too extensive ery- 
thematous or pustular eczema, the fol- 
lowing is of value : Salicylic acid, 5 
to 10 grains (0.3 to 0.6 Gm.) ; pow- 
dered starch and zinc oxide, of each 2 
drams (8 Gm.) ; petrolatum, ^ ounce 
(15 Gm.). 

In psoriasis salicylic ointments are 
of value, especially to remove the 
scales. Crocker recommends salicy- 
lates internally in extensive but re- 
cent psoriasis guttata. In pityriasis 
capitis with marked desquamation 
Cantrell found useful a weak emul- 
sion of salicylic acid in water with 
mucilage of acacia. Pityriasis rubra 
also improved under mild salicylic 
ointments, and mild cases of ichthyo- 
sis were likewise benefited. Lentigo 
was usually cured by strong salicylic 
applications. Indurated, papular acne 
Avas greatl}^ improved, and seborrhea 
of the scalp, chest, or nasal orifices 
favorably influenced. Among the 
other skin conditions in which salicy- 
lic acid has proven of use are erythe- 
ma multiforme, erythema nodosum, 
lupus erythematosus, and miliaria. 
Erythema following horseback riding, 
or intertrigo, may be relieved with a 
2 per cent, salicylic ointment. 

The itching of urticaria may be 
allayed with a dusting powder com- 
posed of salicylic acid, 1 part; zinc 
oxide, 3 parts, and powdered starch, 
6 parts. In chronic urticaria, the in- 
ternal use of 20-grain (1.3 Gm.) doses 
of sodium salicylate is also recom- 
mended. For pruritus of the vulva 



SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 59 

and anus the following' may be used : any part of the growth remains, the 
Salicylic acid, white wax, of each 2 treatment may be resumed and con- 
drams (8 Gm.) ; cacao butter, 5 drams tinned for three days. This, however, 
{20 Gm.) ; oil of nutmeg, 3^ dram is not often necessary. 
(2 CO.). Soft chancres and venereal sores 

In ordinary ringworm (tinea cir- may be dressed with the following 

cinata) a solution of 10 grains (0.6 ointment : Salicylic acid, 20 grains 

Gm.) of salicylic acid in ^^ ounce (15 (1.3 Gm.) ; alcohol, 45 minims (3 c.c.) ; 

Gm.) of collodion is rapidly curative benzoinated' lard, 2 ounces (60 Gm.). 

where the condition is not too long As a dusting powder, 1 part of the 

standing. acid may be mixed with 8 parts of 

In hyperidrosis of the feet, hands, powdered starch or chalk, 
or axillae, a mixture of equal parts of A 1 : 1000 solution of salicylic acid 
powdered salicylic acid and talc or has been employed as a nasal douche 
starch will remove odor and tend to in chronic ozena. In chronic middle- 
arrest the trouble. ear suppuration Foltz has used with 

Where there is a tendency to occlu- satisfaction insufflations of 1 part of 

sion of the ducts of sweat-glands or powdered salicylic acid with 6 parts 

other follicles, mild salicylic oint- of boric acid. 

ments are of value to prevent or over- Thiersch's solution, a non-toxic 

come blockage. fluid available for general antiseptic 

For corns, a saturated solution of purposes, consists of salicylic acid, 1 

salicylic acid in collodion, the creosote part ; boric acid, 6 parts ; dissolved in 

salicylic plaster mull of Unna (6 to water, 500 parts. 

10 parts of the acid and 1 to 2 parts Application of dry powdered sali- 

of creosote spread upon gutta-percha), cylic acid to suppurating and infected 

or the following combination, may be wounds gives excellent results, caus- 

relied on to produce the desired '"^ liquefaction and prompt disap- 

pearance of the scab or slough, leav- 

SO enmg. ^^^ ^ clean, bright-red, granulating 

IJ Acidi salicylici gr. x (0.6 Gm.). surface which heals rapidly. Offen- 

Olei terebinthincE rec- sive odors disappear within 24 hours. 

tificati rn,v (0.3 c.c). It causes no pain or irritation. Doses 

Acidi acetici glacialis ni.ij (0.12 c.c). of 3 to 5 gains (0.2 to 0.3 Gm.) in 

Cocaina- hydrochlo- milk or bismuth suspension give fa-) 

ridi gr. ij (0.12 Gm.). vorable results in typhoid fever. In 

Collodii TTi^c (6 c.c). vitro, 0.2 to 0.5 per cent, of the acid 

M. Sig. : Apply locally. inhibits or destroys Shiga's dysentery 

T- , r • -1 bacillus, the B. typhosus, staphylo- 

l^or removal of warts, smular prep- ct ,.* ^ u 

' ^ ^ coccus, streptococcus pyogenes, B. 

arations are advantageously used. A diphtheria, pneumococcus, and B. tet- 

mixture of salicylic acid and lactic ani. A. Wilson (Brit. Med. Jour., 

acid, of each yi dram (2 Gm.) in 1 Feb. 20, 1915). 

fluidounce (30 c.c.) of flexible collo- ^- E. de M. Sajous 

dion may be applied to the summit ^ ^^^ 

of the wart with a match-stick night ^- ^- ^^ ^- Sajous, 

J • r r -J * Philadelphia, 
and mornmg for hve or six days. 

Soaking the part in water will then SALINE INFUSION. See Infu- 

cause detachment of the slough. If signs Saline. 



60 



SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS). 



SALIVARY GLANDS, DIS- 
EASES OF. —X EROSTOMIA 
(DRY MOUTH).— Symptoms.— 
Arrest of the salivary or l^uccal secre- 
tions was first studied l)y Hutchin- 
son, in 1887. Since then about 40 
cases have been recorded. The 
tongue appears red, devoid of epi- 
tlielium, cracked, and absolutely dry. 
The inside of the cheek and the hard 
and soft palates are also dry, and 
the mucous membrane is smooth, 
shining-, and pale (Seifert). Diminu- 
tion in the nasal and lachrymal secre- 
tions has also been noted, as well as 
dryness of the skin and crumbling' 
or falling out of the teeth. The 
urine is normal. The general health 
and the digestion are unimpaired, 
but swallowing and articulation are 
difficult, owing to the absence of 
moisture. The disease usually reaches 
its greatest intensity rapidly, and 
may then remain without change for 
years. It usually persists until the 
patient dies. 

Etiology and Pathology. — Xero- 
stomia is almost always met with in 
women, and about one-half of the 
cases occur in subjects past 50 
years of age. It sometimes follows 
a shock. It is usually ascribed to 
defective nerve-function, many pa- 
tients showing distinct evidences of 
nervous disturbance: hysteria, hypo- 
chondria, anuria, etc. In some it ap- 
pears to result from mere arrest of 
function without impairment of the 
general health. In 36 cases studied 
by A. J, Hall the state of the salivary 
glands and ducts was as follows: In 
8 cases the parotids were enlarged, 
either equally or unequally ; in 3 
they were tender and painful ; in 4 
they were not so, and in 1 the gland 
ulcerated through into the mouth. In 



5 cases enlargement varied from time 
to time; in 1 of these enlargement 
was most marked at the menstrual 
period. With 1 exception, other 
neighboring salivary glands were 
not enlarged. 

Treatment. — Pilocarpine has been 
used with some success in these 
cases, but the condition usually re- 
curs. Blackman employs the drug in 
/JO- to i/io-grain (0.003 to 0.006 Gm.) 
doses, in a gelatin lamella, which 
is placed on the tongue and moistened 
with water. 

PTYALISM. — Excessive secretion 
of saliva occurs as a symptom of 
rabies, the various forms of stomati- 
tis, especially the mercurial form, 
dentition, various gastric disorders, 
etc. ; but as an idiopathic disorder it 
is rarely met with. It is often ob- 
served in neurotic subjects, especiallv 
children, and usually disappears after 
a few years, when the development 
of the subject has become equalized. 
It occasionally attends pregnancy 
{q. z'.), and may occur during men- 
strual periods and various febrile 
disorders, particularly smallpox. The 
effects of pilocarpine, mercury, iodine, 
copper, and other agents in causing 
ptyalism are well known. 

Treatment. — The general health 
r-equires attention, the idiopathic form 
I'cing in realitv a manifestation of 
debility. Weak astringent washes, 
or a saturated solution of potassium 
chlorate, may be tried. The galvanic 
current, the positive pole being ap- 
plied in the mouth while the latter is 
full of water, the negative pole being 
placed over the thyroid cartilage, 
may prove of value if used daily. 

SALIVARY CALCULUS.— Sali- 
varv concretions of various sizes 
sometimes form in the parotid gland 



SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS). 



61 



and its duct, — Stenson's, — causing in- 
flammation of the organ, retention of 
saliva, and enlargement of the organ. 
The majority of calculi, however, are 
found in Wharton's duct: the duct 
of the maxillary gland. Foreign 
bodies — which, as shown by Desmar- 
tin, frequently enter Wharton's duct 
— often act as nuclei. Klebs and 
Waldeyer contend that masses of 
micro-organisms are the most com- 
mon causes of salivary calculi, the 
phosphates and carbonates of lime, 
magnesia, soda, etc., being deposited 
around them. The stones may be- 
come as large as eggs, and multiple, 
and are occasionally facetted. In 
some cases the inflammatory phe- 
nomena proceed to abscess-formation, 
and, spontaneous rupture taking 
place, a salivary fistula is formed. 
In the case of Stenson's duct the 
opening is opposite the second molar 
of the upper jaw. Wharton's duct 
opens beneath the tongue, under the 
frenum. Both openings can be pene- 
trated with a probe, or a fine needle 
may be inserted into the mass and 
its contents thus recognized. 

Treatment. — It is sometimes pos- 
sible to remove a small calculus 
through the canal ; but, as a rule, it is 
necessary to thoroughly anesthetize 
the part with cocaine and to remove 
the mass by an incision through the 
oral tissues. 

TUMORS OF THE SALIVARY 
GLANDS.— Cysts.— Cystic dilatation 
of the parotid and maxillary glands 
or of tlieir ducts is occasionally ob- 
served, as a result of a superficial 
inflammatory process or of cicatricial 
stenosis of the orifices. In a case 
noted by Stubenrauch the growth — 
a parotid cy<,t — was found studded 
with tubercular nodules. Stenson's 



duct may become inflated with air 
through forcible air-pressure — such 
as that accompanying the playing of 
wind-instruments, glass-blowing, etc. 
— and simulate a cyst. 

In many of these cases it is neces- 
sary to remove the sac wall after 
evacuating the contents by incision. 

Tumors of the Parotid. — Tumors 
of the parotid are often the result 
of implication of the glandular tis- 
sues in neoplasms of neighboring 
structures. They may arise in the 
gland itself, however. Almost any 
variety of growth, especially ade- 
noma, fibroma, chondroma, myx- 
oma and the malignant varieties — 
sarcoma and carcinoma — may be 
encountered. 

The removal of the entire gland 
for large malignant growths necessi- 
tates a grave operation, owing to 
the proximity and frequent involve- 
ment of the external carotid, the in- 
ternal jugtflar vein, and other im- 
portant vascular and nervous struc- 
tures. For this reason, large malig- 
nant neoplasms are removed with 
difficulty and often imperfectly. Arr 
old and good rule in such cases is to 
remove movable growths: i.e., those 
which are not firmly fixed to the un- 
derlying tissues. Benign tumors can 
usually be successfully extirpated. 
After the first free incision is made 
the mass should as much as possible 
be removed by the fingers. The 
facial nerve and the temporomaxillary 
are thus less exposed to injury. 

Tumors of the Maxillary Gland. — 
This gland may be the seat of any 
of the forms of tumor met in the 
parotid, but, like it, is often involved 
in growths that develop in the neigh- 
boring structures, especially carci- 
noma of the inferior maxillary. The 



62 



SALlVAkV GLANDS, DISEASES OF (CRANDALL AND MILLS). 



mass usually projects beneath the 
jaw. The removal is not as difficult 
as is the case of tumors of the parotid, 
the facial and ling-ual arteries, which 
are easily tied, and the ling-ual and 
hypog-lossal nerves, which can easily 
l>e avoided, offering- no obstacle to a 
thoroug-h operation. Here, also, how- 
ever, it is always best to use the fin- 
eers to decorticate, as it were, the 
g-rowth after incision of the superficial 
tissues. 

PAROTITIS. — Inflammation of the 
parotid gland. 

Definition. — Parotitis is usually an 
infectious disease {infectious paro- 
titis), but it may result from injury 
{traumatic parotitis) or from the ex- 
tension of inflammatory or malig^nant 
.processes in adjacent tissues {irrita- 
tive parotitis). 

TRAUMATIC PAROTITIS.— Inflam- 
mation of the parotid gland may cer- 
tainly result from injuries of suf- 
ficient severity to cause an effusion 
of blood into the gland or the tis- 
sues surrounding it. It may also re- 
sult from burns or the application 
of caustics. While micro-organisms 
may take part in the process, the 
condition is quite different from in- 
fectious or septic parotitis. Unless 
infected with septic germs, suppura- 
tion is not common. 

INFECTIOUS PAROTITIS. — Two 
forms of parotitis occur as the direct 
result of germ invasion: 1. Mumps; 
epidemic parotitis. 2. Metastatic, symp- 
tomatic, suppurative, or septic parotitis. 
The writers observed 38 cases in 
which extreme swelling and pain in 
one or both parotid glands had fol- 
lowed typhus or relapsing fever at a 
French hospital in Roumania in 1917. 
The parotitis seemed to be more 
common after typhus, and gangrene 
from arteritis after relapsing fever. 



but these complications occurred in 
some of both. They recall that it is 
due to secondary infection, strepto- 
cocci predominating. Bonnet and de 
Nabias (Lyon Chir., Mar.-Apr., 1919). 

1. Mumps. — Mumps is an acute, 
infectious, contagious inflammation 
of one or both parotid glands, or 
other salivary glands, usually occur- 
ring epidemically. Although inflam- 
mation of the parotid glands may be 
caused by various germs, the disease 
commonly known as mumps gives 
every indication of being a specific 
^disease. A period of incubation, the 
method of invasion, and the definite 
course pursued mark the disease as 
a specific fever. No specific germ, 
however, has as yet been discovered. 
Several micro-organisms have been 
isolated and held by their discover- 
ers to be the causative germ of the 
disease. The last of these at the 
present writing was a micrococcus 
described by Merelli, of Pisa, to 
which he g'ave the name of Micrococ- 
cus tragcnus. The correctness of this 
view has not yet been confirmed by 
other observers. 

In 1908 Granata concluded that the 
virus of mumps may be of the filter- 
able type. • However, neither he nor 
Nicolle and Conseil, who injected 
bacteria-free fluid from the parotids 
in cases of human parotitis, repro- 
duced the disease satisfactorily. 

The writer succeeded in reproduc- 
ing the chief organic lesions of paro- 
titis in animals by means of filtered ex- 
tracts of saliva from human patients. 
The active agent in the infectious 
saliva was found to be neutralized by 
the serum of an animal that had sur- 
vived the injection of testicular and 
parotid emulsions, while the serum 
of a normal animal had no such 
power. Various facts suggested the 
presence of a minute filterable virus. 
Martha Wollstcin (Jour. Exper. Med., 
xxxiii. 353, 1916). 



SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS), 



63 



In S cases of mumps a Gram posi- 
tive diplococcus was isolated from the 
spinal fluid, the blood, and a lymph 
gland by the writer. The injection of 
the organism into the testicle of a 
rabbit produced severe orchitis in 10 
days. These findings confirm the 
earlier reports of similar organisms 
from cases of mumps, and it appears 
probable that mumps is caused by a 
Gram positive diplococcus and not 
by a filterable virus. R. L. Haden 
(Amer. Jour. Med. Sci., November, 
1919). 

Incubation. — The period of incu- 
bation is exceedingly variable. That 
most commonly observed probably 
lies between, 16 and 20 days. It has 
been given by different authorities as 
follows: Flint, 10 to 18 days; Holt, 

17 to 20 days; Ashby and Wright, 
14 to 21 days; Smith, 19 to 21 days; 
Jacobi, 2 to 3 weeks; Dukes, 16 
to 20 days; Dauchez, 15 days; Roth, 

18 days; Henoch, 14 days. 
Symptoms. — Premonitory symp- 
toms are usually slight or entirely 
wanting. In rare cases malaise and 
headache precede the actual onset for 
a week. There is frequently a period 
of invasion lasting from twelve to 
twenty-four hours, marked by fever- 
ishness, headache, muscular pains, 
anorexia, and perhaps vomiting. In 
very many cases the local symptoms 
are the first to appear. Pain is usu- 
ally the first of these. It is stitch- 
like in character and is located in 
the parotid gland, but radiates into 
the ear. It is increased by pressure 
and by all movements of the jaw. It 
increases in severity and in many 
cases becomes very intense. In other 
cases spontaneous pain is not felt, it 
being developed only upon pressure 
or movements of the jaw. Rilliet de- 
scribes three painful points : one at 
the level of the temporomaxillary ar- 



ticulatiorv; one below the mastoid 
apophysis; the third over the sub- 
maxillary gland. Swelling soon en- 
sues, and first appears in the depres- 
sion between the mastoid process and 
the ramus of the jaw, forcing the 
lobe of the ear outward. At first the 
parotid gland alone is involved and 
the swelling assumes the character- 
istic triangular shape, the upper 
angle being just in front of the ear. 
As the surrounding tissues become 
involved, the triangular shape is 
lost. The cheeks, side of the neck, 
and regions behind the ear become 
swelled, the swelling in some in- 
stances extending almost to the 
shoulder. The tumefaction in front 
of the ear, however, remains as one 
of the distinctive marks of parotitis. 
The swelled area is often reddened, 
but more commonly the skin is nor- 
mal in color and appearance. Over 
the gland the swelling is elastic to 
the touch, but the surrounding tis- 
sues are usually edematous and have 
a doughy feeling and may even pit on 
pressure. 

The pharynx and tonsils are fre- 
quently involved by the edema, caus- 
ing much discomfort. When the dis- 
ease is unilateral, the head is inclined 
toward the affected side. When both 
sides are involved, the head is held 
rigidly upright, as every movement 
causes pain. The appearance is char- 
acteristic and striking, and in ex- 
treme cases the patient becomes al- 
most unrecognizable. 

Both sides are usually affected be- 
fore the attack runs its course. They 
may be attacked simultaneously, but 
more frequently the inflammation oc- 
curs upon one side a day or two be- 
fore it appears on the other. Of 228 
cases reported by Holt, both sides 



64 



SALIVARY GLANDS, DISEASES OI- (CRANDALL AND MILLS). 



were affected in 215. The interval is 
sometimes a week or more, but more 
commonly it is not more than three 
days. In unilateral mumps the left 
side is affected more frequently than 
the right. 

The swelling- commonly reaches its 
height on the third day ; it remains 
stationary for two or three days, and 
then subsides witli greater or less 
rapidity. The edema of the sur- 
rounding tissues is the first to dis- 
appear. After the edema has gone 
the gland is sometimes slow to gain 
its normal dimensions. Seven to ten 
days are required for the disease to 
run its course, but the duration of the 
illness depends also upon the interval 
between the involvement of the two 
sides. A patient of my own was con- 
fined to the house almost a month. 
The parotid on the right side was 
attacked a week after that on the left, 
and this was followed by orchitis on 
the eighteenth day. 

The other salivary glands are not 
infrequently involved, and in rare 
cases the submaxillary glands alone 
are affected. 

The secretion of saliva is usually 
diminished, but occasionally it is in- 
creased. This, together with the 
painful swelling of the face, edema of 
the throat, and constitutional symp- 
toms, renders the patient extremely 
wretched. Attempts to examine the 
throat are often futile, the patient 
being scarcely able to open the mouth. 
He will make no attempt at masti- 
cation and refuse food, owing to the 
pain during deglutition. These symp- 
toms are especially prominent when 
the tonsils are involved. Even speak- 
ing is then painful. Although the 
swallowing of acids commonly causes 
severe pain, it does not always do so, 



and the popular belief that it is an 
infallible sign of mumps is erroneous. 
Constitutional symptoms are usu- 
ally not severe. The fever is rarely 
high. The temperature ranges in 
ordinary cases from 100° to 102° F. 
(37.8° to 38.9° C). It frequently does 
not go above 101° F. (38.3° C.) at any 
time during the attack, but in severe 
cases it may reach 104° F. (40° C.) 
or even more. Other symptoms are 
those .common to all febrile condi- 
tions. When the swelling is extreme, 
pressure upon the vessels of the neck 
may cause headache and marked 
cerebral disturbance. Delirium is 
sometimes due to this cause. The 
severity of the disease varies greatly 
in different epidemics. In some the 
children are but slightly ill ; in others 
they are quite seriously so when the 
disease is at its height, and are left 
weak and anemic. 

The blood in mumps shows defi- 
nite changes in the corpuscular con- 
tent consisting (a) in a slight in- 
crease in the total number of leuco- 
cytes, and (b) in a lymphocytosis 
which is both relative and absolute. 
The lymphocytosis is present on the 
first day of the disease and persists 
for at least fourteen days. The oc- 
currence of orchitis does not invari- 
ably alter the blood-picture. The 
blood changes are of distinct diag- 
nostic value in differentiating mumps 
from other inllammatory swellings 
of the parotid or submaxillary sali- 
vary glands and from cases of 
lymphadenitis. A lymphocytosis of 
the cerebrospinal fluid occurs when 
mumps is complicated by meningitis 
or by lesions affecting the cranial 
nerves. It has, however, also been 
found in cases of mumps which have 
presented no clear clinical symptoms 
of any organic lesion of the nervous 
system. From a consideration of the 
blood and cerebrospinal fluid, one is 
justified in assuming that the virus 



SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS). 



65 



of mumps excites an inflammatory 
reaction, the characteristic feature of 
which is a great aggregation of 
lymphocytes. A. Failing '^Lancet, 
July 12, 1913). 

Diagnosis. — The rapid onset and 
almost equally rapid subsidence of 
the glandular enlargement is a most 
characteristic feature of mumps. 
This, together with the location of 
the tumor and its peculiar shape and 
large size, distinguishes it from 
acute enlargement of the lymphatic 
nodes, as well as chronic malignant 
growths. The location of the tumor 
is usually sufficient to distinguish it 
from the cervical swellings of scarlet 
fever and diphtheria, but examina- 
tion of the throat should always be 
made in cases in which there is the 
slightest doubt. 

Etiology. — Although mumps is 
spread by contagion, susceptibility is 
probably less than to any of the 
other contagious diseases. Close 
contact is usually necessary. The 
disease is rarely carried from one 
person to another by a third, but that 
is known to have occurred. The dis- 
ease is rare under 4 years and very 
few cases in infants have ever been 
reported. It is rare in adult life and 
still more so in old age. It is most 
common between the ages of 5 
and 14. 

The exact period of infection is 
doubtful. Contagion is possible from 
the first symptoms or even before the 
swelling of the glands has appeared. 
The power of infection seems to con- 
tinue in some cases for several days 
after the first symptoms have disap- 



Epidemics of mumps occur more 
commonly in the fall and spring than 
at any other season. They vary 
greatly in frequency of occurrence 
and the extent of territory involved, 
occurring in some localities almost 
annually and in others only at inter- 
vals of many years. The infective 
power of the disease varies decidedly 
in dififerent epidemics. Epidemics of 
measles and mumps are frequently 
associated. 

Recurrence of mumps is uncom- 
mon, but is not unknown, as my own 
personal experience has positively 
demonstrated. 

Pathology. — Opportunity for post- 
mortem study of parotitis is so rare 
that its pathology is not yet fully un- 
derstood. So far as known, patho- 
logical changes are confined to the 
salivary glands. Infection probably 
takes place through the salivary 
ducts, the gland-substance being first 
involved. The periglandular tissue 
is involved secondarily. In those 
cases in which pathological exami- 
nations have been made, the salivary 
ducts have been found to be occluded 
by swelling and inflammation of 
their walls. The gland itself is 
hyperemic and edematous. Suppu- 
ration is rare and probably does not 
occur in simple parotitis. Its occa- 
sional occurrence is probably due to 
pyogenic bacteria which have found 
admission with the specific germs. 

Complications and Sequels. 
— Among young children complica- 
tions are rare. Suppuration occurs in 
about 1 per cent, of the cases, accord- 



peared. Isolation, to be effective, ing to Holt, and is usually due to 

must be continued for at least a week some accidental infection by pyogenic 

after the swelling has entirely sub- germs. Deafness, due not to otitis 

sided, or nearly three weeks from the media, but to disease of the auditory 

first symptoms. nerve, has been reported in a very 



8-6 



(£ 



SATJVARV GLANDS, DISEASES OF (CRANDALL AND MILLS). 



few cases. It is usually unilateral 
and permanent. Facial paralysis, 
multiple neuritis, and other nervous 
disorders also occur in very rare in- 
stances, and nephritis is not unknown 
as a sequel. Meningitis and ocular 
complications have also been ob- 
served. Pancreatitis with epigastric 
and vomiting- and glycosuria are not 
uncommon complications. 

The writer has seen many cases 
of epigastric pain with vomiting in 
the last stages of mumps. Out of 20 
cases in one school, 10 followed this 
course, and all showed tenderness to 
pressure over the pancreas. Fox re- 
ports a similar case: On the fifth day 
of mumps a boy developed fever, 
epigastric pain, and vomiting, and a 
deep-seated swelling was felt in the 
epigastric region. There was no 
sugar in the urine, and the boy re- 
covered. Cecil Reynolds (Brit. Med. 
Jour., ii, 352, 1910). 

Pancreatitis may be one or the sole 
manifestation of the acute infection 
called epidemic parotitis. The pain 
and protrusion of the stomach region 
which some writers have explained 
as acute mumps pancreatitis may 
have been merely an acute gastritis 
as a manifestation of the infectious 
process. L. Cheinisse (Semaine med., 
Feb. 21, 1912). 

In the pancreatitis of mumps, pain 
is the most noteworthy symptom; 
tenderness in the region may persist 
after other symptoms have disap- 
peared. Constipation, followed by a 
colliquative diarrhea, is common. 
Fever, epistaxis, profuse sweating, 
irregular pulse, and the facies of 
grippe are also noted. Jaundice may 
supervene. The diagnosis, in view 
of the very obvious mumps, is there- 
fore not difficult. The prognosis is 
favora1)le. Raymond (Paris med., 
Aug. 3, 1912). 

A most peculiar but characteristic 
complication is orchitis. It is most 
common in adolescents and adults 



and is extremely rare ia children. 
Among 230 cases of mumps Rilliet 
and Barthez saw but 10 cases of 
orchitis, only 1 being under 12 years. 
Its frequency undoubtedly varies 
in different epidemics. The disease 
is a true orchitis, but epididymitis 
in rare cases occurs either alone or 
complicating the orchitis. The dis- 
ease is, as a rule, unilateral, and oc- 
curs usually between the eighth and 
sixteenth day of the mumps. A chill 
at the onset is not uncommon, and 
more or less fever is an accompani- 
ment. The acute symptoms increase 
somewhat slowly during a period of 
three to six davs, when thev subside 
and the swelling rapidly diminishes. 
So rapid, in fact, is the return to nor- 
mal conditions that it is clear that 
the inflammation does not go beyond 
the stage of serous exudation. In bi- 
lateral orchitis one side precedes the 
other, as a rule, by one or two days. 
In many cases, as the orchitis de- 
velops the parotitis subsides, which 
has given rise to the theory of me- 
tastasis. 

The writer has had 7 cases of par- 
tial or complete (so complete that not 
a vestige of prostatic tissue could be 
made out) atrophy of the prostate, 
in which an antecedent parotiditis 
seemed to j^e the sole etiological fac- 
tor; in some of these cases (5) the 
atrophy was accompanied by atrophy 
of the testicles; in 2 the testicles 
seemed to be unaffected. W. J. Rob- 
inson (Letter to the N. Y. Med. Jour., 
Mar. 6, 1915). 

In a series of 115 cases, epididy- 
mitis was met by the writer in 20 in- 
stances, in 18 of which it was inde- 
pendent of orchitis. It began about 
the sixth day of the disease and lasted 
fifteen to twenty days. In half the 
cases it was accompanied by distinct 
swelling of the organ, which in the 
remaining instances was merely ten- 



SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS). 67 

der. Inflammation of the vas defer- male patients developed orchitis and 

ens was noted in 40 cases, generally 5.3 per cent, of the women had mas- 

independently of epididymitis or or- titis; that is, about half of the women 

chitis. It began on the second or who were nursing infants at the time. 

third day of the disease, and was bi- Bertelsen (Ugeskrift for Laeger, Dec. 

. lateral in 26 cases. Twenty-three 9, 1915). 

cases showed prostatitis. Enlarge- ^^ ^„*._„„^ n r j- 

r , , , , re ' Treatment. — Cases of ordinary 

ment of the lymph-nodes of Scarpa s . ■' 

triangle was met with in 10 cases, and seventy require but little medication, 

of those of the iliac chain in 6 cases. A mild antiseptic mouth-wash should 

Swelling of the tonsils took place in be given with a view of preventing 

40 cases. Diarrhea was noted for two infection by pyogenic bacteria. The 

or three days in 60 cases. In 2 cases ^.^^ ^^^^^^j^ ^^^ j. j^ ^^^^ ^^^ ^^^^^ 

appendicitis suddenly developed on , , , , • , , -r i • r 

the tenth day; recovery in two weeks should be kept in bed if there IS fever, 

took place in both instances under Warm camphorated oil is the most 

rest, dieting, and local application of soothing application that can be used 

ice. Ramond and Goubert (Presse locally. 

med., Mar. 25, 1915). ^N\,^x^ there is considerable tension 
In females inflammation of the or throbbing, the ice-bag sometimes 
breast or ovaries occurs in very rare gives more relief than warm appli- 
instances. The number of well- cations. In general terms, the treat- 
authenticated cases of this complica- ment is the same as for other febrile 
tion, it must be said, is very small, conditions. 

Involvement of the thyroid gland and Buccal antisepsis, according to 

of the lymphatic nodes has been Martin, diminishes the chances of 

observed testicular complications in parotitis. 

_,'.,, . , A 4 per cent, solution of boric acid 

Prognosis.-Mumps is rarely a ^^^^^ ^^^^^ ^^^^^^^ ^^ ^^.bolic acid 

serious disease. It usually runs an should be employed as a gargle, and 

uneventful course, and under 12 pilocarpine subcutaneously in doses 

years complications are rare. In of % grain (0.01 Gm.) once daily, to 

children of the so-called scrofulous diminish the pain and lower the tem- 

1 ^. . . . perature in cases of orchitis, 

type resolution is sometimes slow ^ ^, . ,, . 

■' ^ The following ointment is recom- 

and imperfect. Among 24,635 cases mended by Tranchet:— 

occurring in the army during the ^ idithyol, 

Civil War there were 39 deaths: a iodide of lead, of 

mortality so high as to lead to each 45 gr. (3 Gm.). 

doubt regarding the accuracy of the Chloride of Ammo- 

statistics. "*'«"* ^^ s^- (2 Gm.). 

„ . , . . . Lard 1 oz. (31 Gm.). 

tpidemic parotitis was never en- 
countered in Greenland until the in- This ointment is to be applied to 
fection was brought in 1913 by a ship the swelled parts three times a day. 
from Denmark, and of the 2425 in- In some instances vaselin may be 
dividuals in the district, about 1500 used in place of the lard, and some- 
contracted the disease. In the times belladonna may be added with 
writer's special district, 191 of the advantage. 

285 individuals were affected, that is, Where fever and severe pain are 

66 per cent, of the men and 68 per present, sodium salicylate is effective, 

cent, oi the women. No infant under It should be combined with an 

2 was affected; 18 per cent, of the alkali: — 



68 



SALIVARY GLANDS. DISEASES OF (CRANDALL AXD MILLS). 



R Sadii salicylat., 

Sodii bicarb aa gr. v (0.3 Gm.). 

Bcnzosnlphinid q. s. 

Aqua q. s. ad fjss (15 c.c). 

Sig. : Ever}' two or four hours. 

Stark (Practitioner, Mar., 1911). 

The application every morning of 
pure tincture of iodine to the pharyn.x 
and buccal mucous membrane, with 
special attention to the gingival fold 
and opening of Steno's duct, is recom- 
mended as a prophylactic by the 
writer from experience in military 
barracks. A tablet of potassium 
chlorate should also be kept con- 
stantly in the mouth. Petrilli (Poli- 
clinico, June 1, 1913). 

The writer tried convalescent 
serum in several cases, using 5 c.c. 
for both subcutaneous and intraven- 
ous injections. Very little reaction, 
lessening of pain, and earlier sub- 
sidence of swelling and of tempera- 
ture were noted. Gradwohl (U. S. 
Naval Med. Bull., Oct., 1919). 

2. Metastatic or Symptomatic Par- 
otitis. — This is an inflammation of the 
parotid gland occurring as a result of 
septic infection through the blood or 
through the buccal secretions, in the 
course of various affections, and often 
ending in ulceration. It may be 
acute or chronic. It is oftenest met 
with in typhoid, typhus, and scarlet 
fevers, cholera, dysentery, plague, 
pyemia, pneumonia, influenza, puer- 
peral fever, erysipelas, and other in- 
fectious disorders. It may result, 
also, from poisoning by mercury, 
lead, and the iodides. Inflammation 
of the testicles is another cause, espe- 
cially when the process is gonorrheal. 
Injuries of the alimentary canal and 
of the testicle or pelvic organs may 
also give rise to it. Parotitis may 
follow abdominal operations, espe- 
cially ovariotomy, hysterectomy, and 
laparotomy for peritonitis. It has 
also been observed in cases of neu- 
ritis, facial paralysis, and diabetes. 



Symptoms. — When acute the gland 
rapidly swells. The tem])erature 
rises to 103° or 104° F. (39.4° or 
40° C). The whole face becomes 
enlarged, when both glands are in- 
volved, and the lids edematous. The 
pain is sometimes very severe, owing 
to the tense capsule with which the 
gland is surrounded. Pus-formation 
promptly follows in the majority of 
cases, and the pus may burrow in 
various directions, — the auditory me- 
atus, the thoracic cellular tissue, the 
retropharyngeal tissues, the maxillary 
joints, etc., — and cause serious lesions 
if not promptly evacuated by incision. 

Parotitis was encountered by the 
writer in 16 of the 760 cases of ty- 
phoid fever in his service. Several 
of the men died. The typhoid was 
always unusually severe in these 
parotitis cases. Cahanescu (Wiener 
klin. Woch., May 27, 1915). 

Case of suppurative parotiditis fol- 
lowing pneumonia in a boy of 3 years. 
Five days later the temperature, 
which had been in the neighborhood 
of 99.5° F. (37.5° C). reached 104° F. 
(40° C). No signs in the chest were 
demonstrable, but on the following 
day a hard, tender swelling appeared 
in the right parotid region. Three 
days later a deep incision below the 
right ear reached an abscess and a 
small amount of pus was removed. 
The smear showed pneumococci and 
a few staphylococci. The tempera- 
ture fell and the recovery was un- 
eventful. J. P. Parkinson (Brit. Jour, 
of Children's Dis., May, 1915). 

In the chronic form — which may 
result from mumps, neighboring in- 
flammatory processes, syphilis, the 
excessive use of mercury, etc. — the 
gland is also enlarged, but less pain- 
ful, and may remain so several years. 

Pathology. — The process is a sup- 
purative one. The pus may dis- 
charge through the cheek or through 



SALOPHEN. 



69 



the external auditory meatus, and 
more rarely into the mouth, esopha- 
gus, or anterior mediastinum. The 
abscess may be confined to the paro- 
tid g-land and its immediate surround- 
ing- tissues or it may be so large as 
to involve the muscles and other soft 
tissues, and even the periosteum of 
the bones. The middle ear is not in- 
frequently involved, as well as the 
central meninges. Thrombosis of 
the jugular and other veins some- 
times leads to septicemia. In rare 
instances the process terminates in 
gangrene. 

Prognosis. — The result depends 
largely upon the condition of the pa- 
tient at the time of the onset of the 
parotitis. If much reduced by the 
primary disease, the complication 
often precipitates a fatal result. If 
it occurs during convalescence and 
the patient is not already reduced, a 
favorable result may be expected. In 
other words, suppurative parotitis in 
itself is not usually fatal. Induration 
and enlargement of the glands is a 
common result. 

Treatment. — By introducing a probe 
into Stenson's duct at the first ap- 
pearance of swelling, and making 
pressure from the outside, a small 
quantity of pus may sometimes be 
evacuated and general suppuration 
.prevented. If this fails, poultices 
should be applied to hasten suppu- 
ration. An incision should be made, 
with antiseptic precautions, as soon 
as fluctuation can be detected. The 
treatment throughout should be that 
appropriate for any acute abscess. 
Floyd M. Crandall, 

New York, 

AND 

H. Brooker Mills, 

Philadelphia. 



SALOL. See Salicylic Acid. 

SALOPHEN.-Salophen (acetyl- 
paramido-phenol salicylate) contains 50.9 
per cent, salicylic acid. It occurs in fine, 
white, odorless and tasteless scales; solu- 
ble in alcohol, ether, alkalies, and hot 
water, and nearly insoluble in cold water. 
It is not official. 

Salophen was introduced as a substi- 
tute for salicylic acid and salol by P. 
Guttmann (Berl. klin. Woch., No. 52, 
'91). It is said to be less poisonous than 
salol or salicylic acid, because the phenol 
of the latter remedies is replaced by an 
innocuous compound of phenol. 

DOSE AND PHYSIOLOGICAL AC- 
TION.— Salophen, like salol, seems to 
suffer no action until it reaches the in- 
testines, when the pancreatic juice splits 
it up into its component parts, salicylic 
acid and acetyl-paramido-phenol. As the 
latter appears innocuous, the further ac- 
tion of salophen is that of its contained 
salicylic acid. It has, however, certain 
advantages over the latter in that it is 
unirritating and tasteless and is not de- 
pressing. It may be given for consider- 
able periods of time without causing 
nausea, anorexia, tinnitus, or other un- 
pleasant symptoms. It possesses antisep- 
tic, antipyretic, and analgesic properties, 
and is given in doses of from 5 to 15 
grains (0.3 to 1 Gm.). The maximum single 
dose is given as 20 grains (1.3 Gm.); not 
more than 90 grains (6 Gm.) should be 
given during the twenty-four hours. 

THERAPEUTICS. — The therapeutics 
of this remedy are the same as those 
of salol and salicylic acid. It is given in 
the same cases, and in similar doses, and 
is generally to be preferred to either of 
them, for the reasons given above. It is 
well suited, also, for use in diseases of 
children. 

Salophen has a most favorable influ- 
ence upon psoriasis, used in 10 per cent, 
ointment. 

Salophen exerts an incontestable action 
upon acute and subacute rheumatism, 
but its effects are less constant than those 
of salicylic acid or sodium salicylate. 
In chronic and blennorrhagic rheumatism 
it has not shown itself superior to other 
drugs. 



70 



SANDALWOOD AND OIL OF SANDALWOOD. 



SANGUINARIA. 



In chronic articular rheumatism it is 
no more useful than the above-mentioned 
drugs. It is an excellent antineuralgic 
and analgesic in cephalalgia, migraine, 
odontalgia; facial, trifacial, and intercos- 
tal neuralgia; am! in the nervous form 
of influenza. It produces good results in 
chorea. It acts well in various skin af- 
fections which are accompanied with itch- 
ing: prurigo, urticaria, pruritus of dia- 
betes, eczema, and psoriasis. 

SALPINGITIS. See Ovaries and 
Fallopian Tubes, Diseases of. 

SALT. See Sodium. 

SALVARSAN See Dioxydiami- 

DOARSENOBENZOL. 

SANDALWOOD AND OIL 

OF SANDALWOOD. -Sandalwood 

(red saunders; santaluni rubrum, U. S. P.) 
is the wood of Pterocarpiis santalinns (nat. 
ord., Leguminosse). It occurs in the form 
of raspings, chips, or splinters. It con- 
tains a red coloring matter of a resinous 
character, known as santalic acid, or san- 
talin, which occurs in fine red, odorless, 
and tasteless needles; soluble in alcohol, 
ether, in concentrated sulphuric acid, and 
in alkalies, but insoluble in water. It is 
used in pharmacy for imparting a red 
color to alcoholic solutions and tinctures. 
It is the coloring principle of the com- 
pound spirit for tincture) of lavender. It 
has no medicinal properties. 

Oil of sandalwood (oil of santal; oleum 
santali, U. S. P.) is a volatile oil distilled 
from the wood of Santaluni aWuin (nat. 
ord., Santalaceje), indigenous to India. 
East Indian sandalwood oil is a rather 
viscid, yellowish, or pale-straw liquid, hav- 
ing ah unpleasant, resinous, harsh taste, 
and a faint but persistent aromatic odor. 
The chief constituent is an alcohol known 
as santalol. 

PHYSIOLOGICAL ACTION AND 
DOSE. — Oil of sandalwood is a stimulant 
in small doses, and an irritant in large 
doses, to the various mucous membranes. 
It checks the secretions of the mucous 
membranes and causes dryness of the 
throat and thirst. S. Rosenberg has 
noticed, after doses of 60 drops a day, 
irritation of the alimentary canal, burning 



in the urethra during micturition, and an 
eruption of small red prominences upon 
the entire surface of the body, involving 
even the conjunctiva;. Large doses may 
produce considerable lumbar pain. 

Its general systemic action is unknown. 
It is apparently more stimulating than oil 
of eucalyptus, and rather less than tere- 
l)ene. It is eliminated l)y the urinary and 
respiratory mucous membranes; the odor 
is sometimes perceptible in the perspira- 
tion. Unlike copaiba, it causes no cuta- 
neous eruptions, and is less likely to pro- 
duce gastric or intestinal disturbance. 
Absorption and elimination are very 
rapid; it may be detected by its odor in 
the urine half an hour after its ingestion. 
It may be given in doses of from 5 to 30 
minims (0.3 to 2 c.c), in capsules or dis- 
solved in alcohol and flavored with cin- 
namon, in emulsion, or on sugar. 

THERAPEUTICS.— Oil of sandalwood 
is an efficient remedy in asthma, chronic 
bronchitis, in the later stage of acute bron- 
chitis, and in the subacute or chronic stage 
of gonorrhea. It is also used as an in- 
gredient of perfumes. It has also been 
used in cystitis, but care should be taken 
to avoid large doses, and thereby the 
urethral scalding pain they cause. 

SANGUINARIA. -Sanguinaria, or 
blood-root, is the rhizome of Sanguinaria 
canadensis (fani., Papaveracese), a native of 
eastern and central North America. San- 
guinaria contains citric and malic acids, 
red resin, and starch, but its important 
constituents are its alkaloids, at least 
five in number, of which sanguinarine 
and chclerythrine are the most important. 

PREPARATIONS AND DOSES.— 
Sanguinaria, U. S. P. (sanguinaria, or 
blood-root). Dose, 1 to 5 grains (0.06 to 
0.30 Gm.). 

Tinctiira sanguinaria, U. S. P. (tincture 
of sanguinaria). Dose, 10 to 40 minims 
(0.60 to 2.60 c.c). 

Sanguinarine (alkaloid). Dose, Yxn to 
y^ grain (0.004 to 0.008 Gm.). 

Fluidextractum sanguinarise, N. F. (fluid- 
extract of sanguinaria). Dose, 1 to 5 
minims (0.06 to 0.30 c.c). 

Syrupus sanguinaria?, N. F. (syrup of 
sanguinaria). Dose, 30 minims (2 c.c), 
representing 6 grains (0.4 Gm.) of san- 
guinaria. 



SANTONICA AND SANTONIN. 



71 



Syrupus pini strobi comp., N. F. (com- 
pound syrup of white pine). Dose, 2 
fluidrams (8 c.c), representing 5 grains 
(0.3 Gm.) each of white-pine bark and 
wild-cherry bark, together with small 
quantities of aralia, populus, sanguinaria, 
sassafras, cudbear, glycerin, alcohol, and 
a little chloroform. 

PHYSIOLOGICAL ACTION.— The 
powder inhaled causes violent sneezing 
and free secretion of mucus. It is feebly 
escharotic. The taste is harsh and bitter. 
In small doses sanguinaria produces a 
sense of warmth in the stomach and stim- 
ulates the secretions. Moderate doses 
produce nausea and depression of the cir- 
culation. In large doses it causes inflam- 
mation of the stomach with intense burn- 
ing, thirst, vomiting, dimness of vision, 
dilatation of the pupils, vertigo, great pros- 
tration and muscular relaxation, cold and 
clammy skin, and collapse. After a pre- 
liminary increase of arterial tension the 
heart action becomes depressed. The 
spinal reflexes are reduced and the spinal 
centers paralyzed. Death is often pre- 
ceded by convulsions either of spinal 
origin or from carbonic acid poisoning 
due to failure of respiration. 

TREATMENT OF POISONING.— 
The stomach and bowels should be 
washed out with warm water. The dif- 
fusible stimulants should be administered. 
Digitalis, amyl nitrite and strychnine 
hypodermically are efficient, with mor- 
phine and atropine, if necessary, to relieve 
pain or severe nausea. The patient should 
be kept warm. 

THERAPEUTIC ACTION. — Sangui- 
naria is chiefly used as a stimulating 
expectorant in subacute and chronic 
bronchitis. 

SANTONICA AND SAN- 

XONIN. — Santonica (Levant or German 
wormseed) is the unexpanded flower- 
heads of Artemisia pauciflora (fam., Com- 
positse), a native of Turkestan and the 
surrounding countries. It contains about 
1 per cent, of volatile oil, IK' to 3 per 
cent, of santonin and a variable amount 
of artemisin. Since the isolation of san- 
tonin from santonica, the use of the crude 
drug has been abandoned. 

Santonin occurs in faintly acid, shining, 



colorless, flattened, rhombic prismatic 
crystals, odorless, and at first nearly 
tasteless, but with a bitter after-taste. It 
is permanent in the air, but turns yel- 
low on exposure to light. It is soluble 
in alkalies and most volatile oils, in 5300 
parts of cold water, 250 parts of boiling 
water, 34 parts of alcohol, 78 parts of 
ether, and in 2.5 parts of chloroform, and 
nearly insoluble in glycerin. Colored 
santonin is an unreliable remedy. 

PREPARATIONS AND DOSES.— 
Santoiiinuui, U. S. P. (santonin). Dose, 
1 to 4 grains (0.06 to 0.25 Gm.) for an 
adult, ^ to K grain (0.015 to 0.03 Gm.) 
for a child. 

Santonica, U. S. P. VIII (santonica). 
Dose, 10 to 40 grains (0.60 to 2.60 Gm.). 

Trochisci santonini, N. F. (troches of 
santonin, worm lozenges), each contain- 
ing K grain (0.03 Gm.) santonin. Dose, 1 
to 4 troches. 

Trochisci santonini compositi, N. F., con- 
taining santonin and calomel, of each, Yz 
grain (0.03 Gm.). 

Sodium santoninate, official in the U. S. 
Pharmacopoeia of 1880, is a very soluble 
salt, a fact which forbids its use and that 
of other santoninates, since the object of 
using this remedy is to act locally upon 
the parasites. When given for other pur- 
poses than as a vermifuge the dose is 5 
to 10 grains (0.30 to 0.65 Gm.). 

PHYSIOLOGICAL ACTION. — San- 
tonin is decomposed in the blood, disturb- 
ing the nutrition of the cerebral centers, 
and producing xanthopsia or chromatopsia, 
a condition where objects appear yellow, 
red, green, or blue, either by staining the 
humors of the eye or by its action upon 
the retina and perceptive centers; the 
urine is stained a greenish-yellow, or, if 
alkaline, a reddish-purple color, due to 
xanthopsin, a derivative of santonin. 
Elimination is by the kidneys, is slow, 
taking about two days for the removal 
of an ordinary dose. There is an in- 
creased flow of urine and more frequent 
micturition. 

POISONING BY SANTONIN.— This 
often occurs l)y children eating freely of 
worm lozenges, or from susceptibility to 
its action. Toxic doses produce alarm- 
ing symptoms — muscular tremors, vertigo, 
cold sweats, mydriasis, stupor and epi- 



72 



SARSAPARILLA. 



leptiform convulsions. Death occurs from 
respiratory failure. A case of urticaria 
occurred after a 3-grain dose to a child, 
and a general niorbilloid eruption and in- 
tense punctiform rash on the buccal and 
faucial mucous membranes after a 5-grain 
dose taken by an adult. 

Treatment of Santonin Poisoning. — The 
treatnu-nt consists of the use of diffusible 
stimulants, hot baths, demulcent drinks, 
belladonna and strychnine, with inhala- 
tions of ether to control the convulsions. 

THERAPEUTIC USES.— The most 
important use of santonin is that of a 
vermifuge to expel the roundworm {As- 
caris lumbricoidcs or the Oxyiiris vcr~ 
micuJaris (thread- or seat- worm) from 
the intestines. It has no efifect upon the 
tapeworm. In persistent incontinence of 
urine santonin has been efficient when all 
other remedies have failed. It is often 
useful when the optic nerve is diseased, 
to restore the activity of vision, and in 
some cases of color blindness. 

As an anthelmintic santonin should be 
administered on an empty stomach. 
Whitla and Demme combine santonin with 
castor oil, but in aggravated cases the lat- 
ter preferred to give it in a slightly 
sweetened oleaginous solution, ^ grain 
(0.03 Gm.) to 1 ounce (30 c.c.) of olive 
oil. A previous saline purgative (mag- 
nesia or rhubarb and magnesia) removes 
the mucus in which worms breed. The 
dose of santonin, given at night, should be 
followed by a saline purgative in the 
morning, preferably before breakfast. 

Santonin has been recommended by 
Whitehead, of Manchester, in amenor- 
rhea, especially when due to chloranemia. 
He gives a 10-grain (0.6 Gm.) dose on 
two successive nights. Cadogan Master- 
man has found this method useful in 
severe uterine colic arising from suppres- 
sion of the menses. 

SAPREMIA. See Wounds, Septic. 
SARCOMA. See Cancer. 

SARSAPARILLA.— Sarsaparilla is 

the dried root of Smilax vicdica, Sinilax 
ornata, Smilax papyracccc, Smilax officinalis 
(fam., Liliacese), and other varieties of 
smilax indigenous to central America, 
Mexico, Brazil, Honduras, and other trop- 



ical and subtropical American countries. 
The roots are without odor and have a 
mucilaginous, bitter and acrid taste. Sar- 
saparilla contains about 3 per cent, of 
saponin-like substance (separable into 3 
glucosides), up to 15 per cent, of starch, 
a little resin, volatile oil, pectin, calcium 
oxalate, etc. The glucosides are the im- 
portant constituents, sarsasaponin, paril- 
lin, and smilasaponin, the last two being 
known as smilaciii. 

PREPARATIONS AND DOSES.— 
Sarsaparilla, U. S. P. (sarsaparilla root). 

Fluidextractum sarsaparilla, U. S. P. 
(fluidextract of sarsaparilla). Dose, J/2 to 
1 dram (2 to 4 c.c). 

Fluidextractum sarsaparillcc compositum, 
U. S. P. (compound fluidextract of sarsa- 
parilla), containing sarsaparilla, 15 parts; 
licorice, 12 parts; sassafras bark, 10 parts; 
mezereum, 3 parts; glycerin, 10 parts; 
and diluted alcohol to make 100 parts. 
Dose, ^ to 1 dram (2 to 4 c.c). 

Syrupus sarsaparillce compositus, U. S. P. 
(compound syrup of sarsaparilla), con- 
taining fluidextract of sarsaparilla (20 
per cent.), fluidextracts of licorice and 
senna (of each 1.5 per cent.), and oils 
of anise, gaultheria, and sassafras (of each 
0.02 per cent.). Dose, 1 to 4 drams 
(4 to 16 c.c). 

THERAPEUTIC USES.— Sarsaparilla 
is probably inert, or nearly so, in the 
dose usually given, though moderate doses 
apparently aid digestion and improve the 
appetite. Its chief value is as a pleasant 
vehicle for disguising the taste of the 
iodides and of the mercurial salts. While 
there is no evidence of a curative action 
of sarsaparilla by itself in syphilis, a tem- 
porary recourse to the remedy has been 
considered useful, especially in debilitated 
patients in whom mercury and the 
iodides have seemingly lost their bene- 
ficial action or have been improperly ad- 
ministered. Phillips recommends this 
remedy in chronic lung affections with 
much wasting; in chronic rheumatism 
and cutaneous disorders with venereal 
taint. Sir Astley Cooper advises its use 
in the cachexia caused by chronic sup- 
puration, in chronic abscesses, ulcers, and 
bone disease. Zittmann's decoction (a de- 
coction of sarsaparilla, calomel, cinnabar, 
alum, senna, licorice, anise-seed and fen- 



SCABIES. 



73 



nel) is much used by the German 
physicians in chronic rheumatism, syphiUs, 
and scrofula. In domestic medicine sar- 
saparilla has been a favorite blood 
purifier. 

SCABIES.— DEFINITION.— An in- 

flammatory contagious disease of the 
skin, due to the presence of the Acarus 
scabici and attended by severe pruritus. 
SYMPTOMS.— The eruption produced 
by the Acarus scabici consists of scattered 
vesicles and papules, which are usually 
located between the fingers and on the 
flexor side of the wrists and elbows. 
The axillae, mons veneris, abdomen and 
buttocks, the penis, the mammse, and in 
children the legs and feet are the points 
of predilection next in order. The bur- 
rows of the parasite resemble scratches, 
which, upon close examination, may be 
seen to be beaded. The Acarus may 
readily be extracted from its burrow with 
the tip of a needle for microscopic ex- 
amination. The eruption is attended by 
severe itching, which is especially marked 
at night. The scratching to which the 
patient subjects the part greatly increases 
the local irritation. The eruption may 
become pustular or complicated by other 
dermatoses (eczema, urticaria, etc.), and 
present various characteristics due to the 
accumulation of epidermic detritus, dead 
acari, etc., or accumulated crusts. The 
hairs of the limbs afifected are often shed, 
and the nails may become hypertrophied. 
Schamberg and Strickler found that of 
forty-seven cases of scabies, over 80 per 
cent, showed 5 or more per cent, of 
eosinophiles; the maximum was 19 per 
cent., and the average 7 per cent, (the 
normal maximum is 4 per cent.). The 
incubation period extends from two days 
to a week. Occasionally the itching is 
absent — apruriginous scabies. During a 
general illness scabies is apt to disappear 
or improve; but the disease reappears as 
soon as convalescence is established. 

ETIOLOGY.— The Acarus scabici is about 
one-quarter millimeter long, and resem- 
bles an eight-footed turtle in general out- 
line; the males live under the skin or epi- 
dermic scales, the females under the 
epidermis in the burrows, where they de- 
posit their eggs. Acarus does not inhabit 



the prickly layer, but the undermost part 
of the middle layer of the epidermis. The 
eczema of scabies is not caused by 
scratching, but by irritating substances 
given off by the Acarus, according to 
Torok. 

While the female mite is visible to the 
naked eye, the male is much smaller. 
Females are more numerous than males, 
and when fecundated penetrate into the 
epiderm, making a burrow in which they 
deposit their ova, from 6 or 9 up to 30 in 
number. The mite cannot retreat be- 
cause of several bristling hairs project- 
ing from her body; she dies in the bur- 
row; the eggs mature in a few days, and 
the resulting larval forms emerge upon 
the surface and become sexually active, 
become impregnated, burrow, deposit ova 
and die, and thus the cycle continues. 
The life of the individual mite is from two 
to three months. The males live on the 
surface near the burrows. The disease is 
very contagious, through contact with af- 
fected individuals and any wearing apparel 
or bedclothing that they may have used. 

TREATMENT.— Scabies may be rap- 
idly cured by adopting Hardy's method; 
scrubbing with soap and water, using a 
brush twenty minutes; the same pro- 
cedure thirty minutes, but with the part 
immersed in the soap-water; rubbing of 
the part with the Helmerich-Hardy oint- 
ment: Carbonate of potash, 25 grains 
(1.62 Gm.); sulphur, 50 grains (3.25 Gm.); 
lard, 5 drams (20 Gm.). — M. This is 
left on two hours and the parts are bathed 
as before, but not brushed. Pruritus 
may usually be relieved by means of a 
2 per cent, menthol ointment. Petrolatum 
is sometimes sufficient. 

The simple sulphur ointment thor- 
oughly, though gently, rubbed in at night 
before retiring, followed the next morn- 
ing by a warm bath, is often sufficient 
to cure scabies when persisted in for two 
or three weeks, but the underwear should 
be very frequently changed and boiled for 
half an hour or baked in an oven at 
120° C. In many cases the ordinary sul- 
phur ointment is too strong; it is always 
best to reduce its strength by mixing 
it with an equal quantity of benzoated 
lard. Sulphur baths are also valuable, 
but ointments can be kept in contact 



74 



SCAMMONY. 



longer with diseased parts, and are there- 
fore more destructive to the parasite. 

Julien recommends painting the entire 
body with balsam of Peru, 3 parts, and 
glycerin, 1 part, which exercises a toxic 
action on the Acarus. No soap and water 
should be used before its application. 
With a l)rush a thin layer of the balsam 
is laid on at night, followed by gentle 
rubbing. A bath is taken on the fol- 
lowing morning. The remedy causes no 
irritation, as a rule. 

For scabies in infants and young chil- 
dren, Hartzcll recommends equal parts of 
styrax and olive oil, or 1 or 2 drams (4 to 
8 Gm.) of balsam of Peru to 1 ounce (30 
Gm.) of vaseline. 

Betanaphthol (20 per cent, ointment), 
styrax, creolin (10 per cent, ointment), 
petroleum, and Hebra's modification of 
Wilkinson's ointment (unguentum sul- 
phuris comp., N. F., which contains pre- 
cipitated chalk, 10; sublimed sulphur, 15; 
oil of cade, 15; soft soap, 30; lard, 30 
parts) have been used with success. 

Scabies has been successfully treated 
with nicotine soap. It is of a dark-brown 
color, and may be scented with oil of 
bergamot. It consists of tobacco extract, 
5 per cent.; precipitated sulphur, 5 per 
cent.; and ovei-fatty soap, 90 per cent. 

After thorough bathing the body and 
limbs may be rubbed lightly with washed! 
sulphur, less than ^ teaspoonful for each 
person; this to be followed by clean 
underclothes and clean sheets with yi 
dram (2 Gm.) of sulphur dusted between 
them. If this is repeated every second or 
third day the cure, in ordinary cases, is 
complete in a week. 

For the treatment of secondary pustular 
complications Knowles, 1918, recommends 
ammoniated mercury ointment, 20 to 40 
grains (1.3 to 2.6 Gm.) to the ounce (30 
Gm.). Incipient boils can be cured by 
daily rubbing for ten minutes with 25 per 
cent, ichthyol ointment. If they are re- 
current, an autogenous vaccine should be 
used. Septic ulceration or cellulitis may 
require rest in bed, and should be treated 
by the local application of ammoniated! 
mercury in zinc oxide ointment. 

Another plan is to change the parasiti- 
cide during the treatment (Montgomery). 
Use a sulphur-balsam Peru ointment for 



three days, a betanaphthol ointment for 
three days, and a creolin ointment for 
the remaining time. 

SCALP. See Head and Brain, 
Diseases and Injuries of. 

SCAMMONY.— Scammony is the 
gum resin from Convolvulus scamnionia 
(fam., Convolvulaceae), derived from the 
living roots of the plant. Its chief con- 
stituent (80 to 95 per cent.) is a gluco- 
sidal resin called scammonium. 

PREPARATIONS AND DOSES.— 
Scammonke radix, U. S. P. (scammony). 
Dose, 4 to 8 grains (0.25 to 0.5 Gm.). 

Rcshia scammonke, U. S. P. (resin of 
scammony). Dose, 3 to 5 grains (0.2 
to 0.3 Gm.). 

Extractum colocynthidis compositiim, U. S. 
P. (compound extract of colocynth, con- 
taining 14 per cent, of resin of scam- 
mony). Dose, 5 to 10 grains (0.30 to 
0.60 Gm.). 

Pilida catharticce compositcc, U. S. P. (com- 
pound cathartic pills containing 1% grains 
(0.08 Gm.) of compound extract of colo- 
cynth in each pill). Dose 2 pills. 

Pilulce catliarticie vegetahiles, N. F. (vege- 
table cathartic pills containing 1 grain — 
0.06 Gm. — of compound extract of colo- 
cynth in each pill). Dose 2 pills. 

It is also an ingredient of pilula colo- 
cynthidis comp. (pil. cocciae), N. F., of 
pilul^e colocynthidis et hyoscyami, N. F., 
and of pilula colocynthidis et podophylli, 
N. F. 

PHYSIOLOGICAL ACTION.— Scam- 
mony is a drastic hydragogue and feebly 
cholagogue purgative. When given alone 
it causes considerable griping. It is un- 
certain in action by reason of its frequent 
adulteration and its insolubility in the 
gastrointestinal juices if they are acid. 
Gastritis and enteritis, if present, contra- 
indicate its use. Given in large doses it 
may cause severe gastroenteritis and 
fatal purgation. It should not be given 
alone, but combined with other cathartics 
and aromatics, to modify its harsh action. 
Its effects are usually manifested within 
four hours. 

THERAPEUTIC USES.— On account 
of its tastelessness it is a favorite pur- 
gative in children, combined with calomel 



SCARLET FEVER (CRANDALL AND MILLS). 



75 



and triturated with sugar of milk. It is 
useful in cerebral affections and dropsies, 
in the form of compound extract of 
colocynth. It is useful to clear the 
intestines of mucus and as an anthel- 
mintic against both roundworms and 
tapeworms. It is a purgative well adapted 
to cases of obstinate constipation and 
impaction of feces and in cases of mania 
and hypochondriasis. W. 

SCARLET FEVER. —Scarlatina. 

DEFINITION.— Scarlet fever is 
an acute, infectious, contagious, erup- 
tive, disease presenting-, in typical 
cases, the following features : After 
a period of incubation of from two to 
four days there is a sudden onset of 
sore throat, vomiting, and fever; 
within twenty-four hours a character- 
istic eruption appears and continues 
for about six days, when it terminates 
in desquamation. 

While the average period of incu- 
bation of scarlet fever (i.e., the period 
between exposure and the appearance 
of symptoms) has been stated to be 
from two to four days, with a maxi- 
mum of seven, the latest observations 
show that this period is very vari- 
able. The limits of the period of 
incubation are practically from four 
to twenty days, with an average of 
ten to fourteen days. J. W. Scheres- 
chewsky (Public Health Reports, 
Nov. 27, 1914). 

SYMPTOMS.— From the attack so 
mild that diagnosis is difficult to the 
fiercely malignant form we see every 
possible degree of severity. Notwith- 
standing this variability of type, the 
majority of cases pursue a fairly 
uniform course, and may, with pro- 
priety, be called ordinary cases. 
Other types may be described as mild, 
severe, and malignant. 

Ordinary Type. — The invasion is 
usually sudden, and is marked by 
vomiting, fever sore throat, and rapid 



pulse. Occasionally a short period of 
malaise precedes the onset of definite 
symptoms. In older children a chill 
is sometimes the first symptom; in 
younger children a convulsion. The 
vomiting is usually repeated several 
times, and is not accompanied by 
nausea. When it occurs late in the 
disease it is a far more unfavorable 
symptom than at the outset. The 
intensity of the period of invasion is 
usually indicative of the severity of 
the attack, though this is a rule sub- 
ject to many exceptions. 

The temperature is frequently 
found to be 103° F. (39.4° C.) at the 
first visit and may reach 104° or 105° 
F. (40° or 40.5° C.) on the first day. 
A temperature on the first day above 
104>^° F. (40.2° C.) indicates a severe 
attack; below 102° F. (38.9° C.) a 
mild attack. The highest point is 
commonly reached at the height of 
the eruption. It then begins to sub- 
side and becomes normal at a varying 
period, ranging from the ninth to the 
fifteenth day. The fever is frequently 
remittent and in mild cases almost 
intermittent in character. There is 
no typical temperature range. The 
febrile stage, even in quite severe 
cases, may be limited to six or seven 
days, or it may be prolonged to four- 
teen or fifteen days without obvious 
cause. 

Any extensive rise or fall from the 
level maintained during the fastigium, 
or a rise interrupting the progressive 
lytical resolution indicates an inter- 
current or complicating condition 
and not an essential part of the scar- 
latina pyrexia. Lysis in scarlatina 
begins on the fifth or sixth day, so 
that if a febrile case shows the be- 
ginning of lysis on the second day 
thereafter, we know that the case was 
four days old on admission. The 
existence of a complication is re- 



76 



SCARLET FEVER (CRANDALL AND MILLS). 



vealcd by a sudden rise during the 
lytical stage, the character of the 
complication being often shown by 
the temperature curve, and the 
changes in the pulse and respiration 
rate. A somewhat septic curve with 
increase in pulse and respiration sug- 
gests bronchopneumonia; a cardiac 
complication may be suspected from 
a suspension of the lytical tempera- 
ture curve with greatly increased 
pulse rate and a moderate increase in 
respiration; a meningitis or menin- 
gismus attending an otitis media or 
mastoiditis is frequently indicated 
through an interruption of the stage 
of lysis by an increase of fever of 
septic character coupled with a lower 
pulse rate than is usual at the height 
of the fever, although it might also 
indicate the presence of an acute glo- 
merular nephritis. Nephritis is not 
as frequent in hospital cases as in 
private practice for two reasons: The 
patient is kept strictly in bed until 
desquamation is almost complete and 
is kept on a fluid diet until he has 
well passed the stage of acute symp- 
toms. H. W. Berg (Med. Record, 
May 11, 1912). 

In a study of 17 cases of uncom- 
plicated scarlet fever and of 2 cases 
of scarlet fever with nephritis, the 
writers found that examination of the 
urine for albumin is of more value 
than the functional tests for the de- 
tection of the onset of kidney com- 
plication. Veeder and Johnston 
(Amer. Jour, of Dis. of Children, 
Mar., 1920). 

A pulse abnormally rapid as com- 
pared with the height of the tempera- 
ture is quite characteristic of scarlet 
fever. It is often 150 on the first day, 
and continues rapid throughout the 
disease. 

One of the earliest symptoms is 
sore throat. The fauces, tonsils, and 
pharynx are of a imiform bright-red 
color, and on the hard palate numer- 
ous dark-red macules may be seen. 
In mild cases the throat symptoms 



may be very slight; in more severe 
cases the tonsils may be studded with 
follicular spots, or smeared over with 
a tenacious exudate closely resem- 
bling a pseudomembrane. There is 
frequently a discharge from the nose, 
which may consist of clear, tenacious 
mucus or mucopus. The glands at 
the angle of the jaw frequently be- 
come enlarged. Gregor of Petrograd 
has recently reported observations 
upon the thyroid and believes that 
there is a special form of scarlatinal 
thyroiditis. It is possible that these 
changes may have some bearing upon 
the occurrence of thyroid disease in 
later life. The spleen is not usually 
enlarged. 

Not one of the individual symp- ' 
toms can be depended upon to estab- 
lish the diagnosis. Next to the 
throat, the condition of the tongue 
is the most reliable symptom, some 
enlargement of the papillae of the tip 
and border being usually observable, 
although this symptom is much more 
frequently missing than is the angina 
and may occur in other conditions. 
Miller (Arch, of Pediatrics, Apr., 
1912). 

As the disease progresses, the 
tongue, which is at first coated, often 
assumes the so-called strawberry ap- 
pearance. 

Considerable confusion exists as 
to what the strawberry tongue really 
is. It is not a white tongue with red 
papilL-e ; such a tongue is seen in vari- 
ous conditions. The true strawberry 
tongue was originally described by 
Flint as follows : "The tongue in the 
first days is usually coated. In the 
progress of the disease the tongue 
usually exfoliates, leaving the surface 
clean and reddened and the papillae 
enlarged. The appearance is strik- 
ingly like that of a ripe strawberry. 




Differential Diagnosis of Eruptions in Children's Diseases. 

1. Scarlet fever. 5. Strawberry tongue of scarlet fever. 

2. Scarlet fever ; desquamation. 6. Variola. 

3. Rubeola. 7. Variola ; confluence. 

4. Rubella. 8. Varicella. 

9. Variola-like varicella. 



SCARLET FEVER (CRANDALL AND MILLS). 



17 



The strawberry-like tongue is a 
pathognomonic symptom ; it is pecul- 
iar to this disease. It is often, but 
not uniformly, present." The term 
should be applied to the red, clean 
tongue with prominent papillae which 
follows a coated tongue. 

The eruption usually appears with- 
in twenty-four hours after the initial 
vomiting. It is not infrequently seen 
after twelve hours, and is sometimes 
delayed for thirty-six hours and in 
rare cases to the fourth or fifth day. 
There is frequently intense itching 
or burning of the skin. The rash is 
usually well developed during the 
second day of its appearance. It 
then continues from four to six days, 
when it gradually subsides. It usu- 
ally appears first over the front of the 
neck and upper part of the chest. It 
consists of minute points of bright- 
scarlet color closely grouped together 
on a slightly reddened skin. They 
become confluent in places, forming 
bright-scarlet patches, but over the 
most of the surface they remain dis- 
crete throughout. Being hyperemic 
in nature, the rash disappears on 
pressure, leaving, for a perceptible 
time, a white spot. An eruption of 
very fine vesicles is seen in rare in- 
stances, and occasionally a blotchy 
eruption appears early on the face, but 
subsides as the typical rash develops. 

One of the most characteristic 
symptoms of scarlet fever is the des- 
quamation. It rarely begins before 
the sixth day, and is frequently de- 
layed until the second week. It ap- 
pears first on the neck and between 
the fingers. It begins as fine, branny 
scales, but soon changes to large 
lamellar scales. Sometimes the skin 
can be peeled oflf in strips. It con- 
tinues from ten to thirty days, and is 



most persistent where the skin is 
thickest. It frequently continues 
about the fingers and nails after other 
portions of the body are clear, which 
explains the readiness with which the 
disease is conveyed by letters. When 
the skin has received careful atten- 
tion, the desquamation is sometimes 
almost imperceptible. In rare in- 
stances a second desquamation occurs. 

The urine becomes scanty and 
high colored during the febrile stage, 
and frequently contains a slight 
amount of albumin and sometimes 
blood and hyaline casts. Except in 
the more severe forms, suppression is 
rare and dropsy still rnore so. These 
symptoms usually subside as the fever 
falls. The kidney symptoms at this 
stage rarely prove serious. They 
may, however, do so, and always de- 
mand attention. The more serious 
kidney symptoms occur later and will 
be considered as a complication. 

Mild Type. — Scarlet fever is some- 
times so mild as to render diagnosis 
very difficult. The symptoms may be 
so slight that medical aid is not 
sought. As a rule, however, there is 
an onset of vomiting, fever, and sore 
throat, as in the ordinary type, but 
none of the symptoms are urgent. 
The vomiting is not persistent, the 
temperature does not rise above 102"" 
or 103° F. (38.9° or 39.4° C), and the 
throat presents only the symptoms of 
mild pharyngitis. I have seen an un- 
doubted case in which the tempera- 
ture never rose to 101° F. (38.4° C). 
It may become normal on the fourth 
or sixth day. The eruption is often 
very faint, and may not appear on the 
face. It may, however, be bright and 
distinctive for twenty-four hours and 
then fade away so rapidly as to have 
disappeared by the fifth day. In rare 



78 



SCARLET FEVER (CRANDALL AND MILLS). 



instances it is an evanescent rash 
which disappears entirely within 
twenty-four hours. Nephritis may be 
a sequel, due in many cases to ex- 
posure and lack of care : the natural 
results of so mild an illness. Owing 
to this lack of care and isolation, the 
patient may become very dangerous 
to others. It is by these mild cases 
that the disease is sometimes sown 
broadcast. A mild attack in one child 
may produce a malignant one in an- 
other. 

Severe Type. — Not only are the 
symptoms of this type severe, but the 
various stages are prolonged. The 
fever may continue for three weeks or 
more, and the stage of desquamation 
for even a longer time. A fatal ter- 
mination is common, death occurring 
usually during the second week. The 
chief peculiarity which distinguishes 
this from the ordinary type is the 
presence of septic symptoms due to 
streptococcic infection. The type 
might, therefore, with propriety be 
called complicated type. The throat 
is usually the first to show the evi- 
dence of streptococcic invasion. On 
the third day, and in some cases on 
the first or second day, a membranous 
exudate appears on the tonsils and 
soon invades the pharynx and naso- 
pharynx. A purulent nasal discharge 
appears, and the lymphatic glands at 
the angle of the jaw begin to swell, 
the cellular tissues being so involved 
as to often cause immense enlarge- 
ment. The Eustachian tubes are in- 
volved, and purulent otitis media fol- 
lows ; but the lar3aix commonly 
escapes. 

In 10,000 cases recorded in ten 
years, 2L06 per cent, had ear disease. 
There are two forms of scarlatinal 
otitis. The first is a comparatively 
mild ordinary inflammation, and has 



no rchuion to the scarlet fever except 
that it occurs at the same time. It 
is most frequent in cases with little 
or no throat trouble. The second 
type is the so-called scarlatino-diph- 
theritic or necrotic otitis, and is 
brought about by the same specific 
cause as the scarlet fever itself. It 
differs from the first type in being 
very much more severe and involv- 
ing extensive necrosis of the soft 
parts and bones. P. Manasse 
(Monats. f. Kinderheilk., July, 1913). 

The urine contains albumin and 
perhaps blood-cells and hyaline and 
epithelial casts. Symptoms of gen- 
eral septic infection rapidly super- 
vene. There is low delirium or 
stupor; the child refuses nourishment 
and may die from exhaustion ; but 
sudden death is not uncommon. 
Others, after overcoming one com- 
plication after another, slowly recover 
after a tedious convalescence. 

Malignant Type. — Though very 
rare, malignant scarlet fever does 
sometimes occur. It begins with 
convulsions and hyperpyrexia. The 
scarlatinal poisoning may be so in- 
tense as to cause death within twenty- 
four hours. More commonly, death 
does not occur before the third or 
fourth day, the patient being coma- 
tose or delirious. The nervous symp- 
toms are so marked that some 
waiters have given to this type the 
name of cerebral scarlet fever. In a 
case of my owii the initial symptoms 
were convulsions, hyperpyrexia, and 
hematuria. 

The writer encountered 16 cases of 
scarlet fever with the clinical mani- 
festations of meningitis among 400 
scarlet-fever patients in the course of 
nine months. When the fluid escaped 
under high pressure on luml)ar punc- 
ture, great relief followed, but when 
the pressure was not high, the lum- 
bar puncture did not seem to benefit, 



SCARLET FEVER (CRANDALL AND MILLS). 



79 



but it proved very instructive by per- 
mitting the exclusion of a suppura- 
tive or serous meningitis. The prog- 
nosis did not seem to be affected by 
the pseudomeningitis, as the severity 
of the scarlet fever was what deter- 
mined the outcome. Sachs (Jahrb. f. 
Kinderheilk., Bd. Ixxxiii, Suppl, 
1911). 

Surgical Scarlet Fever. — Patients 
who have undergone surgical opera- 
tions are unquestionably very sus- 
ceptible to scarlet fever. Such scarlet 
fever, however, is not essentially dif- 
ferent from the usual disease. It is 
simply scarlet fever in a surgical case. 
It is, no doubt, true, as Osier has 
shown, that the eruption which has 
frequently led to a diagnosis of scar- 
let fever is nothing more than the red 
rash of septicemia. It is a fact that 
surgical scarlet fever is much less 
common since surgical septicemia has 
become less frequent. 

In 12 out of 28 cases of scarlet 
fever developed among hospital pa- 
tients, the infection followed an ex- 
tensive operation and in 1 a severe 
burn. The incubation was only three 
days in 10 and from five to eight days 
in the others. The infection doubt- 
less occurred in the operating room. 
Kredel (Arch. f. klin. Chir., Bd. 
Ixxxvii, nu. 4, 1908). 

DIAGNOSIS AND ETIOLOGY. 

— Age is first among the predisposing 
causes. The disease is rare under one 
year, l)ut I have seen an undoubted 
attack of scarlet fever in an infant of 
one week. Up to 5 years the suscep- 
tibility steadily increases and reaches 
its maximum; after 8 years it rapidly 
decreases, and is slight during adult 
life. Sex does not influence its 
occurrence. 

A patient of the writer developed 
typical scarlet fever while nursing 
her month-old babe. The disease ran 
the usual course without complica- 



tions and the infant continued to 
nurse and thrive without contracting 
the disease. Scarlet fever is rare in 
infants less than a year old, and it is 
possible, he thinks, that the mother's 
milk confers a passive immunity on 
the child. Delmas (Arch, des med. 
des enfants, Feb., 1911). 

Scarlet fever is rare in breast 
babies, particularly during the first 
six months. It is more common in 
boys. The complications during the 
first half-year are more frequent and 
more severe, the most serious being 
gangrenous sore throat, and the most 
frequent lymphadenitis. L. V. Ak- 
senoff (Roussky Vratch, Sept. 29, 
1912). 

Of 3603 cases of scarlet fever an- 
alyzed by Pospischill and Weiss 
there were only 28 cases during the 
first year, and these had their in- 
cidence during the later months of 
the year. The author had the oppor- 
tunity of observing 9 cases of scar- 
let fever in infants less than 3 
months of age and 1 case in an in- 
fant 9 months old. With the excep- 
tion of the last, all were the infants 
of mothers suffering from scarlet 
fever. 

The clinical phenomena in all of 
these cases were somewhat as fol- 
lows: From three to seven days fol- 
lowing the onset of the disease in 
the mother the infant took sick with 
a moderate fever lasting from two to 
four days. There was the character- 
istic tongue with the reddening of 
the tonsils and of the soft palate. In 
no instance was there any membrane 
on or necrosis of the tonsils. There 
was at first some difficulty in nurs- 
ing and a disinclination to take the 
breast. Carl Levi (Beitrage z. Klinik 
d. Infektionsk. u. z. Immunit., Bd. ii, 
nu. 2, 1914). 

That scarlet fever is an infectious 
disease does not admit of doubt, but 
the specific germ has not yet been 
discovered. Three theories have been 
advanced as to its etiology, namely, 
that it is due to (1) streptococci; (2) 



80 



SCARLET FEVER (GRAND ALL AND MILLS). 



protozoa; (3) a filterable or ultra- 
microscopic virus. That it is caused 
by a protozoon is possible, but the 
theory has by no means l)een con- 
firmed. The filterable theory cannot 
be excluded, but is largely theoretical. 

The scrum of scarlet-fever patients 
contains specific antibodies for an 
unknown virus. This unknown virus 
seems to be present especially in the 
cervical lymph-nodes. K. K. Koess- 
ler and J. M. Koessler (Jour, of In- 
fectious Dis., Nov., 1911). 

It has been fully demonstrated that 
streptococci play an important role 
in the causation of many of the symp- 
toms. It has been urged by some that 
streptococci are the cause of the dis- 
ease itself, but this ground is unten- 
able. They are, however, the cause 
of the pseudomembranous exudations 
of the throat, and undoubtedly cause 
the otitis and adenitis, and probably 
the nephritis, pneumonia, and joint 
lesions. The streptococci thus far 
found cannot be differentiated from 
other streptococci. The evidence 
fails to support the belief that the 
streptococcus of scarlet fever dififers 
from that of other infectious processes. 

The writer examined the blood of 
523 children suffering from scarlatina 
for streptococci, and concludes that 
the organism is found only in 2.1 per 
cent, of all cases. V. N. Klimenko 
(Arch, des Sci. Biol., St. Petersburg, 
No. 3, 1912). 

The cause of scarlet fever has 
never been definitely determined and 
the attempts to transmit it to mon- 
keys have met with only very limited 
success. The writer believes that it 
is a streptococcic infection, though 
this assumption has not been proved 
or disproved with certainty. Many 
clinical facts seem to prove that a 
special susceptibility on the part of 
the patient is an important factor in 
the development of scarlet fever, and 
that it may be regarded as an anaphy- 



la':tic reaction to a streptococcic in- 
fection. Kretschmer (Jahrb. f. Kin- 
derhcilk., Sept., 1913). 

Whatever the cause of the primary 
disease may be proved to be, it is 
certain that streptococci are the di- 
rect cause of the secondary symptoms. 
They are so constant in their pres- 
ence, and so active in the production 
of the more serious symptoms and 
complications, that they must be re- 
garded as important factors in the 
production of the clinical picture 
which we know as scarlet fever. The 
disease as it commonly appears is a 
mixed infection, the more malignant 
and fatal symptoms being due not so 
much to the primary as the secondary 
infection. 

Staphylococci and diphtheria bacilli 
are sometimes found in conjunction 
with streptococci. 

The inclusion bodies studied by 
Dohle, of Kiel, have been farther 
studied by Nicoll and Williams, of 
New York. These are small bodies 
found in the protoplasm of the poly- 
morphonuclear leucocytes. While 
some observers regard them of im- 
portance in the diagnosis of scarlet 
fever, it cannot be said that their true 
significance has as yet been deter- 
mined. Thev are rarely found after 
the sixth day of the disease. 

Other diagnostic signs have in recent 
years been proposed, the value of which, 
as is the case with Dohle's sign described 
above, has not as yet been determined. 

Dohle's leucocytic inclosures are 
found in many other conditions. 
Their absence, however, is of diag- 
nostic significance, because they are 
found in the early stages of all scar- 
let fevers; a negative result therefore 
excludes scarlet fever, and the early 
diagnosis of the disease may be made 
by their presence. A. Belak (Deut. 
med. Woch., Dec. 26, 1912). 



SCARLET FEVER (CRANDALL AND MILLS). 



81 



The writer has examined a number 
of scarlet-fever patients for the cell 
inclusions, 14 with pneumonia and a 
number of patients with other affec- 
tions, including 11 with anemia and 
5 with measles. The inclusions were 
found constantly in every case of re- 
cent febrile scarlet fever, less numer- 
ous in the milder cases and declining 
as the disease progressed. After the 
seventh day scarcely any were to be 
found. They are no aid in diagnosis, 
therefore, after the first few days, 
and they are not pathognomonic for 
scarlet fever, as they occur with the 
same constancy and as abundantly 
in croupous pneumonia in children. 
Schwenke (Miiiich. med. Woch., Apr. 
8, 1913). 

Leede's sign (Miinch, med. Woch.. Feb. 
7, 1911) is obtained in the following way: 
Apply a rubber band to the arm suffi- 
ciently tight to render the veins very con- 
spicuous and the forearms and hands 
cyanotic, without obliterating pulse. After 
ten or fifteen minutes remove the band. 
Put the skin of tlexor surface of elbow on 
stretch, to render it anemic. Hemorrhagic 
extravasations on this surface, appearing 
as very fine, dark points, favor a diagnosis 
of scarlatina, while their absence speaks 
strongly against the presence of this 
affection. 

The writer confirms the findings of 
Rumpel and Leede in regard to 
petechial hemorrhages from artificial 
stasis in scarlet fever. He has no- 
ticed this phenomenon frequently in 
making blood examinations in scar- 
let fever, and found it positive in 26 
out of a series of 32 cases. In doubt- 
ful cases in children, where the 
throat signs were suspicious, a posi- 
tive result was always confirmed by 
the development of typical scarlet 
fever. Bennecke (Miinch. med. 
Woch., Bd. Iviii, S. 740, 1911). 

Study of 100 patients with various 
affections to determine the diagnostic 
value of the Leede sign. It was not 
positive in healthy controls, but was 
found positive in heart disease, bron- 
chitis, pneumonia, acute hepatitis and 
nephritis, cerebral hemorrhage, ty- 



phoid and puerperal fevers, and tabes. 
These findings deprive the sign of 
any specific diagnostic value. It 
seems to be a manifestation of dimin- 
ished resistance in the walls of the 
smaller blood-vessels. U. Morandi 
(Gazz. degli Ospedali, Apr. 2, 1912). 
The tourniquet or Rumpel-Leede 
sign occurs regularly in scarlet fever, 
but is found also in measles, and in 
some cases of diphtheria, syphilis 
and tonsillitis. It permitted an early 
diagnosis of scarlet fever in a num- 
ber of the writer's cases, before the 
eruption developed. Meyer (Deut. 
med. Woch., Oct. 24, 1912). 

Pastia's sign (La Tribune medicale. No. 
46, p. 726, 1910) consists in a deep-rose- 
colored, linear exanthem in the skin-folds 
of the anterior aspect of the elbow. The 
lines are usually two to four in number. 
They can be caused to stand out in con- 
trast by exerting gentle pressure on skin, 
then quickly removing it. It was uni- 
formly present in 12) cases, appearing with 
the rash and usually lasting two or three 
weeks longer than the rash. It occurs in 
other diseases, but only in such as can 
easily be differentiated from scarlatina. 

The Wassermann reaction, according to 
Rubens (Berl. klin. Woch., Oct. 19, 1908), 
will, under certain conditions that have 
remained undetermined, prove positive in 
Sicarlet fever as it does in syphilis. 

Case of scarlet fever in a girl, 16 
years old, in which Wassermann's 
test for syphilis produced a posi- 
tive reaction. Four weeks after the 
commencement of the illness the 
test became negative, and remained 
so. Holzmann (Miinch. med. Woch., 
Apr. 6, 1909). 

The writer examined 55 scarlet- 
fever patients and obtained a positive 
Wassermann reaction in 18. This 
positive reaction occurs after the 
subsidence of the acute symptoms 
and generally only in the severer 
cases. It usually disappears by the 
end of the period of desquamation 
and has no effect on the diagnostic 
importance of the reaction in syphilis. 
Jakobovics (Jahrb. f. Kinderheilk., 
Feb., 1914). 



8-6 



82 



SCARLET FEVER (CRANDALL AND MILLS). 



The diazo-reaction seems to afford aid 
in identifying scarlet fever from measles. 
The diazo-reaction was found pcjsi- 
tive by the writers in 17.3 per cent, 
of scarlet fever, but also 12.9 per 
cent, of diphtheria patients during the 
first week of these infections. It is 
during this week that scarlatiniform 
serum rashes are so apt to develop 
and make a differential diagnosis from 
scarlet fever quite difficult. The per- 
centage of positive reactions in 
serum sickness was much lower. The 
value of the diazo-reaction in dif- 
ferential diagnosis is very slight. Yet 
the reaction being positive in 75 per 
cent, of cases of measles, a negative 
reaction in a case presenting a mor- 
billiform rash is of value in the dif- 
ferential diagnosis from measles. 
Woody and Kolmer (Arch. of 
Pediat., Jan., 1912). 

Copper sulphate may produce a fleet- 
ing exanthem and other signs suggesting 
scarlet fever. 

Copper sulphate is used for spray- 
ing grape-vines in France, and 2 
children who had been eating grapes 
thus sprayed developed symptoms 
deceptively simulating scarlet fever. 
The diagnosis of scarlet fever was 
made without hesitation, but it had 
to be revised, as the children were 
quite normal again by the fifth day. 
Vomiting, sore throat, headache and 
a lively rash over the entire body 
were the main symptoms. Lasalle 
(Arch, de med. des enfants, Feb., 
1916). 

Leucocytosis is found in virtually 
all cases, the maximum being reached 
during- the first week in uncom- 
plicated cases. It then gradually 
subsides. 

Comparing the findings in 10 cases 
of scarlet fever with those in 7 of 
typhoid, pneumonia, gonorrhea or 
gastroenteritis, the writer concludes 
that a typical polynucleosis accom- 
panies the onset of the eruption in 
scarlet fever. It is pronounced and 
remains high during the first two or 
three days of the eruption, even in 



very young children. The number of 
mononuclears declines, especially the 
proportion of lymphocytes. The 
eosinopliiles fluctuate, but are gener- 
ally increased, especially by the end 
of a few days of the disease. Pater 
(Arcli. de med. des enfants, Aug. 
1909). 

Transmission. — Grave doubts have 
been expressed in recent years re- 
garding the ability of the desquama- 
tion scales to transmit the disease. 
No positive statements can be made 
until the actual cause of the disease 
has been demonstrated. I can only 
express the personal opinion that evi- 
dence against the belief in the trans- 
mission of the disease by desquama- 
tion scales and clothing has not been 
fully established. 

Scarlet fever is not communicable 
in the early stages, but is transmitted 
mainly by the secretions from the 
mouth, nose and ears. The exfoliated 
epithelium, after the fourth or fifth 
week, does not seem able to carry 
contagion. Zangger (Correspondenz- 
blat. f. Schweizer Aerzte, Mar. 1, 
1909). 

Many cases of scarlet fever are so 
atypical as to go unrecognized until 
a sequela makes its appearance. It 
is a disease of direct infection; it is 
rarely carried by a second person or 
object. The most contagious period 
is early in the disease during the 
period of angina, rash and tempera- 
ture; therefore, the danger of trans- 
mitting the disease during the des- 
quamation period is much exagger- 
ated. Kerley (Amer. Jour, of Dis. 
of Children, Jan., 1911). 

So long as nasal and aural dis- 
charges exist, just so long will cases 
of scarlet fever be infective. Sexton 
(Arch, of Diag., May, 1915). 

Experiments seem to show that the 
specific germ of scarlet fever exists in 
the blood, for inoculation with the 
cerum into susceptible animals pro- 
duces a typical attack of the disease. 



SCARLET FEVER (CRANDALL AND MILLS). 



83 



It is also found in the various secre- 
tions, as shown by their power to 
generate the disease. 

The micro-organism, while more 
tenacious of life than is that of most 
other diseases, either lacks the power 
of gaining a foothold, when implanted 
in the system, or is less readily con- 
veyed through the air. It is at least 
a fact that many more children escape 
scarlet fever than measles, and its 
spread is more readily controlled. 

The chief source of infection is the 
patient himself, but the area of con- 
taoion is limited to a few feet. The 
desquamation scales have long been 
regarded as extremely infectious. 
Their retention by clothing, bedding, 
and the walls of the rooms is one of 
the most common causes of infection. 
The purulent secretions from the 
throat, nose, and ear are also very 
infectious, and are probably the chief 
sources of infection. . 

Scarlet fever is spread by indirect 
infection more frequently than any 
other disease except diphtheria. Its 
specific micro-organism is more tena- 
cious of life than that of any other 
disease, except, perhaps, smallpox. 
Authentic cases have been reported in 
which it maintained its vitality for a 
year or more. It may be conveyed 
from one child to another in the fur 
of cats and dogs, and it is probable 
that these animals may suffer from 
the disease. The contagion clings to 
rooms with great tenacity, being usu- 
ally lodged in the wall-paper or in 
cracks of the walls, ceilings, and 
floors. The conveyance of scarlet 
fever by milk and other articles of 
food is undoubted. 

The celebrated epidemics of Hen- 
don and Wimbledon were believed by 
Dr. Klein to be due to scarlet fever 



in the cows, but this belief has not 
been substantiated. It is probable 
that the disease from which those 
cows suffered was not true scarlet 
fever. 

An .epidemic of scarlet fever that 
occurred in the city of Evanston, near 
Chicago, in the winter of 1906-7 
showed conclusively a connection be- 
tween the extension of the disease 
and the use of milk from a certain 
source of supply. This source had 
been under suspicion on account of 
a number of cases of scarlatina oc- 
curring during the previous summer 
and fall, but the real epidemic began 
early in January, 1907, and was at its 
height between the 14th and 19th of 
the month. Whole families were at- 
tacked in a day, and a notable pro- 
portion of the patients were adults. 
H. B. Hemenway (Jour. Amer. Med. 
Assoc, Apr. 4, 1908). 

The disease has been conveyed 
by letters written by hands in the 
stage of desquamation. An attendant 
upon a case of scarlet fever may carry 
the infection to other children by the 
clothes, hands, or beard. 

The portal of entrance in most cases 
is undoul)tedly the nasopharynx. It 
is here that the first local symptoms 
appear, and all the evidence points to 
the fact that both the primary and 
secondary micro-organisms commonly 
enter the system at this point. 

In cities scarlet fever is endemic, a 
few cases appearing in the health- 
reports every week, but at intervals it 
becomes epidemic, usually during the 
fall and winter. Epidemics of scarlet 
fever usually spread very slowly as 
compared with those of measles. 

Period of Incubation. — The period 
of incubation is shorter than that of 
any other infectious disease, except, 
perhaps, grippe and diphtheria. Tlie 
extremes range from a few hours to 
fifteen days. In 87 per cent, of cases 



84 



SCARl.IiT FEVER (C' RANDALL AND MILLS). 



Holt found the period to be less than 
six days and in 66 per cent, between 
1\vo and three days. 

Period of Infection. — The period of 
infection is long. The disease is not 
infectious during the period of incu- 
bation, but it may be so from the first 
appearance of changes in the throat. 
The most actively contagious period 
is at the height of the febrile stage: 
on the third, fourth, and fifth days. 
The infectious power then diminishes, 
but increases again during the stage 
of desquamation. The period of con- 
tagion continues until the last evi- 
dences of desquamation have disap- 
peared. The purulent discharges 
from the throat, nose, and ears are 
capable of infecting others, and isola- 
tion should not be relaxed until they 
have disappeared. The conventional 
forty days is not, in most cases, too 
long. It should be as much longer as 
the condition of the skin and mucous 
membranes may indicate. 

Report of 45 personal cases in 
which children discharged from the 
hospital as fully cured of scarlet 
fever, the forty-second day, infected 
other members in the home to which 
they returned. In 6 cases the chil- 
dren gave the infection in four days 
to other children after their return; 
in some others the interval was from 
five to twenty-five days, but in the 
majority it averaged seven. It is still 
a question how long a child with 
scarlet fever should be isolated. The 
present six weeks' rule is inadequate. 
The best plan would be to have spe- 
cial convalescent homes for children 
with scarlet fever and diphtheria. 
Baginsky (Deut. med. Woch., Apr. 
18. 1912). 
PATHOLOGY. — In uncomplicated 
scarlet fever the lesions are confined 
to the skin and throat. The lesions of 
the skin are those of acute dermatitis. 
The papillae and the stratum beneath 



become infiltrated with fluid, while 
about the blood-vessels there are 
aggregations of leucocytes. The pro- 
duction of epithelium is greatly in- 
creased during the acute stages, which 
result later in profuse exfoliation of 
the superficial layers. In the later 
stages in addition to this, according 
to Neumann, there is also a profuse 
development of exudative cells, par- 
ticularly among the ducts and fol- 
licles. These cells easily reach the 
epithelial surface : a fact which ac- 
counts for the great infectiousness of 
the desquamating cells. 

The throat changes in uncompli- 
cated scarlet fever are catarrhal in 
nature, and are an essential part of 
the disease. The croupous and diph- 
theritic membranes must be consid- 
ered as complications. The patho- 
logical changes in the tongue are 
similar to those in the skin. 

Complications and Sequelae. — An- 
gina. — Except in a very few mild 
cases, the throat always shows some 
pathological change. A catarrhal 
condition of the throat is normal to 
scarlet fever, but membranous exu- 
dates and gangrene are not essential 
to it. 

The true nature of the membranous 
inflammation seen in scarlet fever was 
long a subject of discussion, which 
has been settled by the bacteriologist. 
With few exceptions, the angina of 
the early stages is pseudodiphtheria, 
that of the late stages true diphtheria. 
While primary pseudodiphtheria is a 
mild disease, the death rate being 
rarely over 5 per cent., secondary 
pseudodiphtheria is very dangerous 
and fatal. The membrane may ap- 
pear on the throat on the first or 
second day, but it is not usually seen 
before the third day. It is generally 



SCARLET FEVER (CRANDALL AND MILLS). 



85 



confined to the tonsils, but frequently 
nils the throat and nasopharynx. It 
shows a tendency to invade the ears 
and nose and to shun the larynx. It 
reaches its height about the sixth 
or seventh day. It frequently pre- 
sents all the local characteristics of 
diphtheria together w^ith the general 
symptoms of septicemia. The excit- 
ing cause of this membranous inflam- 
mation is the Streptococcus pyogenes. 
It is occasionally associated with the 
Staphylococcus aureus or alhus, but the 
streptococcus is the more commonly 
observed. It occurs not only in the 
pseudomembrane and the tissues 
underneath it, but is found in the 
blood in large numbers. Through the 
agency of the toxins which it gener- 
ates it is unquestionably the cause of 
the complications and general sep- 
ticemia. The pseudomembranes which 
appear late in the disease are usually 
associated with the Klebs-Loffler 
bacillus. Diphtheria is, in the fullest 
sense of the word, a complication, and 
is not an essential symptom of scar- 
let fever. 

Otitis, next to angina, is the most 
common complication, and in its re- 
sults is one of the most serious, as it 
is a common cause of deaf-mutism. 
It results from extension of the in- 
flammation from the throat through 
the Eustachian tubes. The tendency 
to ear involvement varies in different 
epidemics, but it is more common in 
young patients. It does not usually 
occur until the second week, and, as 
a rule, involves both ears. Its pres- 
ence may be indicated by earache and 
an increase in the fever, but fre- 
quently a discharge is the first indica- 
tion that the ears are involved. The 
process is prone to be a destructive 
one and to result in long-continued 



suppuration. It sometimes leads to a 
lapidly fatal meningitis. 

Adenitis and cellulitis are com- 
mon results of streptococcic invasion 
of the throat. Not only are the 
lymphatic glands themselves enlarged, 
but there is more or less inflammatory 
edema of the surrounding tissues. 
That this is due to secondary infection 
is shown by the fact that streptococci 
are found in abundance in both the 
nodes and edematous tissues around 
them. Enlargement of the nodes may 
be detected during the first week, but 
serious cellulitis does not, as a rule, 
occur until later in the disease. Sup- 
puration, sloughing, or even gangrene 
may occur. 

Joint Lesions. — Although acute ar- 
ticular rheumatism sometimes occurs, 
the joint affection often called scar- 
latinal rheumatism is, in most in- 
stances, a synovitis. It is mild, and is 
frequently confined to the wrist. It 
appears early in the second week, con- 
tinues for three or four days, and dis- 
appears, suppuration being rare. It 
is seldom seen under 4 years. Pyemic 
arthritis occurs in extremely rare in- 
stances, and affects the larger joints, 
the lesions being multiple. Marsden 
has recently offered the following 
excellent classification of the scar- 
latinal joint lesion: (a) synovitis, {b) 
acute or chronic pyemia, (c) acute or 
subacute rheumatism, and (d) scrof- 
ulous disease of the joints. 

Nephritis. — Albumin may be found 
m the urine during the acute stage ; 
but it is fel)rile albuminuria, due to 
degenerative nephritis, which sub- 
sides as the temperature falls. In the 
grave type kidney lesions may occur, 
to which the term septic nephritis has 
been given. The urine contains albu- 
min, but blood and casts are not 



86 



SCARLET FEVER (CRANDALL AND MILLS). 



necessarily present, neither do the 
rational symptoms of uremia appear. 

The most characteristic and com- 
mon kidney lesion is postscorlatinal 
nephritis, and is a diffuse nephritis. 
It develops during- the third or fourth 
week, and may follow a severe or mild 
attack. There may be no interval of 
apyrexia between the kidney attack 
and the onset of the nephritis. It 
may be so mild as to almost escape 
notice, or it may be so severe as to 
cause speedy death. Recovery may 
be complete or incomplete. The first 
symptom to be noticed is usually 
edema of the face, which is frequently 
accompanied by feverishness and rest- 
lessness. Dropsy and all the charac- 
teristic symptoms of acute. nephritis 
rapidly develop. The urine usually 
shows a small amount of albumin for 
a few days before the advent of defi- 
nite symptoms. As the disease de- 
velops, the urine becomes scanty and 
high colored, and may be completely 
suppressed. It contains a large 
amount of albumin, and is loaded with 
blood-cells and casts. The first evi- 
dence of albumin after the second 
week should be a warning of dan- 
ger, and should receive immediate 
attention. 

Pneumonia, although commonly 
found at the autopsy in patients who 
have died with septic symptoms, is 
frequently not recognized before 
death. Endocarditis and pericarditis, 
though uncommon, are sometimes en- 
countered. Murmurs are occasionally 
heard during th^ course of the disease, 
which disappear as the active symp- 
toms subside. Permanent organic 
lesions sometimes develop in conjunc- 
tion with the late kidney complica- 
tions. Nervous symptoms are rare. 
The various serous membranes are 



occasionally involved. Peculiar at- 
tacks of symmetrical, superficial gan- 
grene have been reported. The dis- 
ease may be complicated by any of 
the other infectious diseases. 

Second attacks of scarlet fever are 
extremely rare. They sometimes oc- 
cur, but in most supposed cases there 
has been some error in diagnosis. 
Relapses are more common than 
second attacks. They result from 
autoinfection, and usually occur dur- 
ing the second or third weeks. 

The writer has met 180 return 
cases infected by 145 scarlet-fever 
patients dismissed from the hospital 
as completely cured and disinfected. 
The period of incubation of the re- 
turn cases was from three to fifteen 
days in 80 per cent, and from fifteen 
to twenty-five in the remainder. Of 
the 4178 cases of scarlet fever de- 
clared during the year in question, 
2392 were treated in the hospital in 
his charge. None of the adults gave 
occasion for the return cases; they 
occurred with children who were 
much embraced and petted. Preisicn 
(Berl. klin. Woch., June 21, 1909). 

PROGNOSIS.— The younger the 
patient, the greater the mortality. 
Holt, after the study of a large num- 
ber of American and European cases, 
concludes that the general mortality 
may be assumed to be from 12 to 14 
per cent., while under 5 years it is 
from 20 to 30 per cent. It is much 
lower in private practice than in hos- 
pitals. The majority of fatal cases 
occurs in children under 7 years. 

The prognosis depends upon: 1. 
Amount of poison that has been ab- 
sorbed. 2. Whether the child is weak 
and delicate or strong and robust. 3. 
The occurrence of complications, 
especially cardiac, pulmonary, renal, 
and otitic. Very high temperature 
indicates a bad prognosis. The 
younger the child the graver the prog- 



SCARLET FEVER (CRANDALL AND MILLS). 



87 



nosis. Mortality is estimated at from 
20 per cent, to 30 per cent, in children 
under 5 years of age. Causes of 
death: L Scarlatinal toxemia. 2. 
Nephritis. 3. Brain abscess from ex- 
tension. H. Brooker Mills (Therap. 
Gaz., May, 1921). 

Prognosis becomes unfavorable on 
the appearance of the following symp- 
toms, the gravity being in propor- 
tion to their severity : Violent onset, 
high temperatures, convulsions, ex- 
tensive pseudomembranous or gan- 
grenous pharyngitis, diphtheria, 
croup, pneumonia, extensive cellulitis, 
superficial gangrene, nephritis, and 
exhaustion with general septic symp- 
toms. The prognosis in uncompli- 
cated cases is good. 

Sudden death is not uncommon in 
this disease, and is usually due to 
myocardial trouble. Weill and Mouri- 
quand (Presse med., Aug. 5, 1911). 

Morbidity of over 7,000,000 cases 
collected and studied from communi- 
ties in America, Europe and else- 
where. The most striking fact about 
case-fatality of scarlet fever in the 
past half-century has been its con- 
sistent, general and marked reduc- 
tion. The sexes, as a whole, show 
about equal susceptibility. During 
the first five years of life males are 
more susceptible to the disease, while 
between 5 and 15 years females are 
distinctly more susceptible. Case- 
fatality is higher among males at all 
ages. Nearly half of the scarlet fever 
cases was found to occur in the five 
years between 3 and 8 years of age, 
distributed nearly equally in each of 
the five years, and 2 children out of 
3 at this age contract the disease, 
when exposed to it in their homes. 
Ninety per cent, of cases occur un- 
der 15 years of age. Mortality is 
highest in infancy, being from 12 to 
20 per cent.; lowest at about 10 years 
of age, and thereafter gradually in- 
creases with age. About 90 per 
cent, of deaths occur under 10 years 



of age. H. H. Donnally (Wash. 
Med. Annals, Nov., 1915). 

PROPHYLAXIS.— In view of the 
gravity of the disease and the efifect- 
iveness of preventive measures, pro- 
phylaxis assumes unusual importance. 
The most important of all prophylac- 
tic measures is complete isolation of 
the sick. This applies to nurse as 
well as to patient. If possible, one 
'person should be selected as an inter- 
mediary between the nurse and the 
family. The doctor should always 
wear, in the sick-room, a gown of 
muslin or calico fastened at the neck 
and waist, and long enough to com- 
pletely cover his clothes. A stetho- 
scope should be used in making phys- 
ical examinations of the chest. 

The period of isolation should not 
be less than forty days and as much 
longer as the presence of desquama- 
tion or purulent discharges may de- 
mand. 

The best prophylactic treatment is 

the removal of enlarged and diseased 

adenoids and tonsils. 

Scarlet fever having appeared in 2 
pupils in a school of over 300, the 
2 patients were at once isolated and 
the throats of all the contacts sprayed 
with a 1 : 2000 solution of mercury 
perchloride. No other cases ap- 
peared, and the remaining children 
appeared in perfect health, save for 
the fact that in 131 cases out of the 
remaining 299 an elevation of tem- 
perature varying between 99° and 
101° F. (37.2° and 38.3° C), and last- 
ing for two or three days, was found. 
There were absolutely no other 
symptoms or indications of the chil- 
dren being out of sorts. Thornton 
(Brit. Med. Jour., Feb. 29, 1908). 

In the last 28 years 4251 cases of 
scarlet fever have been reported at 
Brunn. Sterilization of the premises 
and measures to prevent infection of 
others failed in a large number of 



88 



SCARLET FEVER (CRANDALL AND MILLS). 



cases. It is evident that the virus is 
transmitted not only in the period 
of incubation, but long after recov- 
ery, far beyond the routine six 
weeks. The aim should be to re- 
move the virus from tlie mouth by 
mechanical means. Kokall (Wiener 
klin. Woch., Dec. 29, 1910). 

Numerous observers of late, espe- 
cially in England, have shown that 
by the cleansing treatment of nose 
and throat with a mild antiseptic 
healthy children could be kept in con- 
tact with children ill with scarlatina 
without contracting the disease. The 
writer has treated 2 families, 6 chil- 
dren in each family, where one mem- 
ber had contracted scarlatina, and by 
the simple process of cleaning the 
nose and throat three times a day for 
six weeks he has prevented any fur- 
ther spread of the disease. Schultze 
(Med. Rec, Dec. 10, 1910). 

Dischargees from the patient should 
be disinfected with strong subHmate 
sokitions. The bedding, carpet, and 
clothinp- should be disinfected with 
boiling water or steam. The mat- 
tress should be destroyed. The room 
itself should be thoroughly washed — 
floor, ceiling, and walls — with a 
1 : 2000 sublimate solution. 

One room on the top floor of every 
house should be arranged for a sick- 
room : the moldings should be plain, 
and the floor of hard wood ; the walls 
and ceilings should be painted or cov- 
ered with washable paper ; the bed- 
stead should be of enameled iron. It 
is a fallacy to suppose that dishes in 
the sick-room, filled with antiseptic 
fluids, can limit the spread of the dis- 
ease, or that there is any efficiency, as 
a prophylactic, in generating steam 
impregnated with medicinal agents. 
The use of such agents is liable to 
generate a false sense of securitv and 
lead to the neglect of more important 
measures. 



[The child should have its own 
dishes. Everything should be disin- 
fected before it leaves the room — i.e., 
sheets, pillow-cases, towels, and 
everything used for the patient — in 
bichloride of mercury solution 1 :500 
or phenol solution 1:50; also the 
urine and feces, which should be col- 
lected in a bed-pan containing equal 
parts chloride of lime and strong vine- 
gar. So far as possible use materials 
that can l)e burnt. Diapers could be 
made of old sheets, and napkins could 
be made of paper. Hang a sheet at 
the door and keep it wet with either 
of the solutions! mentioned, as this 
will catch the dust from the outside 
and infected material from the inside 
of the room. Sprinkle one of these 
solutions on the floor, or mop once or 
twice a day. Have a gown and cap 
handng- at the door and a pair of rub- 
ber overshoes for your own use. 
Take the tjown off at the door of the 
sick-room, and have it disinfected be- 
tween visits. When you leave the 
room, go to the bath-room and wash 
the hands and face in a weak bichlo- 
ride solution. The mail should also 
be carefully disinfected before it 
leaves the house, using dry heat, and 
all animals kept out of the sick-room 
during the illness, as they are great 
carriers of the infection. — H. Brooker 
Mills.] 

Streptococcic vaccines have been 
tried. The most satisfactory of these 
so far has been Gabritschewsky's, 
reference to which has already been 
made on page 342 in the second vol- 
ume of the present work. 

Gabritschewsky's vaccine for scarlet 
fever is made from streptococci iso- 
lated from the blood in the hearts of 
children dead of scarlet fever. It is 
a condensed bouillon culture of 



SCARLET FEVER (CRANDALL AND MILLS). 



89 



streptococci killed by heating to 60° 
C, and the addition of Yz per cent, 
carbolic acid solution. Each c.c. con- 
tains 0.02 to 0.03 of the bacterial 
mass. The vaccine was first used in 
Moscow in 1904. Usually 10 drops 
were injected with an ordinary hy- 
podermic syringe. The injections 
were made during an epidemic of 
scarlet fever, 185 persons being thus 
treated, as a preventive measure. A 
rise of temperature was observed in 
all but one. A moderate rise in 64 
persons, a faint rise in 54, a marked 
rise in 66. Local tenderness was 
seen in 66 patients, redness in the 
injected area in 173; swelling in 103. 
In many cases there was a rash re- 
sembling true scarlet fever, and in 5 
patients there was desquamation. 
There was a general rash in 43 per- 
sons, a local rash in 70; no rash in 
72 of the 185 patients; only 2 devel- 
oped scarlet fever; the remainder re- 
mained well, save that they showed 
these temporary complications after 
the use of the vaccine. Schamarine 
(Roussky Vratch, June 30, 1907). 

The streptococcus vaccines, used as 
advocated by Gabritschewsky, have 
some influence in controlling epi- 
demics of scarlet fever. Their use, 
with proper care, is attended by no 
harmful results. They should be 
given a wider application in this 
country to prove or disprove the con- 
tentions of the Russian physicians. 
Smith (Boston Aled. & Surg. Jour., 
Feb. 24, 1910). 

After using the Gabritschewsky 
vaccine in 700 cases the writer con- 
cluded that it had a decided value 
from a prophylactic standpoint. In 
comparing the effects observed he 
states that but one very light case of 
scarlet fever has occurred among the 
nurses who have received vaccine 
treatment, while in a considerably 
smaller group, under identical condi- 
tions, 5 developed severe cases of 
scarlet fever. Walters (Jour. Amer. 
Med. Assoc, Iviii, 546, 1912). 

During a severe epidemic of scarlet 
fever in a number of villages the 



writer used Gabritschewsky's bac- 
terins, making about 3000 inocula- 
tions. The results were very satis- 
factory. It was found, however, that 
a single inoculation does not confer 
immunity, and that immunity does 
not last over six months. Poloteb- 
nova (Roussky Vratch, July 14, 
1912). 

[A physician should not attend an 
obstetric case while in attendance 
upon a patient suffering with scarlet 
fever. — H. Brooker Mills.] 

TREATMENT.— Many specifics 
for scarlet fever have been proposed, 
tried, and found wanting. Much may 
be done to avert complications and to 
render them less serious when they 
occur, and many lives may be saved 
by judicious management. Mild cases 
require little or no medication ; they 
usually receive too much. 

The patient should be kept in bed 
for at least three weeks, and should 
receive a fluid diet for not less than 
two weeks. Milk is the best diet for 
scarlet-fever patients. It may be 
given peptonized or plain. Later in 
the disease broths, eggs, or meat- 
jellies may be given. The stoinach 
should never be overfilled. 

[The diet should be liquid and 
nourishing. If the child is breast-fed, 
have the milk pumped from the breast 
and fed to the child. If a bottle baby, 
dilute one-half with water if on 
straight milk, because whole milk 
constipates and causes tympanites, or 
give half milk and half Vichy water, 
because alkalies help to neutralize the 
acidity, which is one of the causes of 
the nei:)hritis. Orange juice is very 
beneficial. Lemonade is good, espe- 
cially if one adds to every pint (500 
c.c.) 1 dram (4 Gm.) of cream of tar- 
tar. Cereals may be cautiously added, 
and water should be given freely. 



90 SCARLET FEVER (CRANDALL AND MILLS). 

Avoid the use of salt and exclude The throat symptoms of the first 

soups and bouillon from the diet. — few days may be mitif^^ated by giving- 

H. Brooker Mills.] cool water or bits of ice. Later hot 

The initial vomiting usually re- drinks may be given or irrigation of 

quires no treatment, ]:)ut the bowels the back of the throat with a weak 

should be acted upon mildly by small, hot saline or boric acid solution may 

repeated doses of calomel. Later be employed. Chlorate of potash 

they should be kept acting, if possible, should l)e avoided. Its beneficial 

by means of enemata rather than by efifects are doubtful. Nasal syringing 

the use of cathartic drugs. should be avoided unless clearly in- 

In severe cases stimulants are re- dicated by a purulent nasal discharge 
quired. In malignant cases they or obstruction of the nasopharynx, 
should be pushed to the point of More harm than good may result from 
tolerance. Strychnine is of great overzealous attempts at local treat- 
value in septic cases with prostration ; ment of the throat and nose. The 
it may often be combined to advan- most successful treatment consists in 
tage with digitalis. Bathing the sur- the use, not of active and poisonous 
face with warm water followed by antiseptics, but of mild and cleansing 
anointing with plain or carbolic vase- washes, freely and frequently applied. 
lin or a 5 per cent, ichthyol ointment [As to the toilet of the nose and 
should be begun as soon as the first throat: Swab, spray, or gargle with 
signs of desquamation appear, and alkaline solution, according to the age 
should be continued throughout the of the child. If the patient be old 
course of the disease. enough to gargle, this should be 
For the itching, which is sometimes done ; if, on the other hand, it be too 
intolerable, keeping the .child restless young for that, but old enough to 
and irritable, the writer finds spong- opg^ J^S mouth and put out its tongue 

ing the body with a warm solution i ^. u *. j ,i i i • 

, ,. u . / • .- when told to do so, then swabbmg 

of sodium carbonate (gram x — Gm. i i , •, . 

0.6-to-5j-60 c.c), to which a little "^''^y ^'^ employed, while, if it be too 

mucilage has been added, very useful young to do this, spraying with an 

and soothing. Seymour Taylor (Med. atomizer would be better. Potassium 

Bull., Aug., 1907). permanganate, gr. ss (0.03 Gm.), 

Tepid baths (28° to 32° C.-82.4° to ^^ter f,j (30 c.c), is a good solution 

89.6° F.) of 20 minutes' duration and , r .• it-, 

., to use lour times a day. Do not use 

given every evening, or it necessary, . , , 

morning and evening, will often in- Potassium chlorate for the sore throat, 

duce sufficient sedation. The un- because of its well-known irritating 

pleasant sensation of heat in the skin effect on the kidneys should any of it 

is also allayed by such baths, though be swallowed or absorbed. After 

still more effectually by rubbings .,^; .i ii i- i i.- • --i r 

.,, r • using the alkaline solution instil a few 

with the following liniment: — , . , •■, . ., 

■drops m each nostril of anv oily prep- 

Cold cream, _ aration, such as :- 

Neutral glycerin aa 50 Gm. (12 'jr). 

M. Ft. linimentum. ^ Menthol gr. x (0.65 Gm.). 

The liniment should preferably be '^''^"'^^ ''^^ &''• 'J ^^-^^ Gm.). 

used luke-warm. A. F. Plicque 01. eucalypt fSss (2.0 c.c). 

(Med. Bull.; N. Y. Med. Jour., July Liq. albolem ....q. s. fSij (60 c.c). 

27, 1912). H. Brooker Mills.] 



SCARLET FEVER (CRANDALL AND MILLS). 



91 



Adenitis can only be controlled by 
checking the septic process at its 
fountain-head in the throat. The ap- 
plication of hot oil or the hot-water 
bag is soothing to some patients, but 
the use of cold is preferable in most 
cases. Poultices should not be ap- 
plied continuously. Diffuse suppura- 
tion requires free incision. Otitis re- 
quires the treatment demanded by the 
disease in other conditions. The 
joint affections require but little treat- 
ment other than rest and protection. 
Rheumatism should receive its own 
appropriate treatment. Restlessness 
and nervous symptoms are sometimes 
relieved by cold to the head, or by the 
use of small doses of phenacetin, not 
enough being given to materially 
affect the temperature. Nephritis 
should receive prompt and very care- 
ful attention. Tts treatment is that of 
nephritis due to other causes. 

A study of 325 cases, with 23 
deaths, in the Alexandra Hospital, 
Montreal, showed that twenty-one 
days' milk diet and twenty-one days' 
bed should be the rule to prevent 
death from nephritis J. McCrae 
(Montreal Med. Jour, Sept., 1908). 

The temperature may require atten- 
tion from the outset, but it should 
not be forgotten that a high tempera- 
ture IS normal to scarlet fever. It 
may be allowed to run, therefore, 
without interference, to a somewhat 
higher point than in most other dis- 
eases. Hyperpyrexia, or a tempera- 
ture continuously above 104° F. 
(40° C), demands treatment. It is 
best reduced by means of the cold 
bath; l)Ut this, for obvious reasons, is 
less practical in private than in hos- 
pital practice. The cold pack or cold 
sponging are more available. An 
effective method of applying cold 



adopted at the Willard Parker Hos- 
pital IS thus described by Northrup: 
"The tendency in all cooling processes 
is for the feet to become cold. To 
obviate this the patient is placed upon 
blankets, but the legs, feet, arms, and 
hands are wrapped in warm, dry 
blankets, and hot bottles are inclosed 
in the wrappings. An ice-bag is ap- 
plied to the head. The face and 
trunk are freely sponged in wann 
water and alcohol, evaporation being 
hastened by fanning, so long as it 
cools the patient, clears the cerebrum, 
gives force and improved rhythm to 
the heart, and leaves the patient to a 
quiet sleep." 

Great caution should be exercised 
in the use of antipyretic drugs. No 
coal-tar antipyretics should be used. 

[Treat the temperature hydrothera- 
ipeutically — i.e., sponge baths, colonic 
irrigations, ice-bags, etc. In cases of 
very high temperature, and especially 
with diminution of urine, once a day 
wrap the child in a blanket and place 
it in water at a temperature of 90° to 
95° ; keep it there for from 10 to 12 
minutes ; take out of wet blanket and 
place in dry blanket, and give inunc- 
tion of cacao butter. Try to have two 
rooms, one for day and one for night, 
preferably with a sunshine exposure. 
Keep temperature of rooms at 68° to 
70° F.— H. Brooker Mills.] 

In all cases in which hypodermic 
injections of large doses of quinine 
bihydrochloride were given the infec- 
tion was cut short. The fever yielded 
after the second or third injection, 
desquamation rapidly supervened, and 
prompt recovery followed. A. Tram- 
busti (Semaine med., June 18, 1913). 
The writer uses quinine bihydro- 
chloride, giving a 30 per cent, solu- 
tion hypodermically in full doses. A 
single injection is said to reduce the 
temperature rapidly and to improve 



92 



SCARLET FEVER (CRANDALL AND MILLS). 



the subsequent course. Chichkine 
(Gac. Med. Catalan., Jan., 1915). 

Serum treatment has been tested 
very extensively, but 1 feel con- 
strained to say that up to the present 
time it has not proved of the value 
hoped for. It is certain that the stock 
antistreptococcus serums have not 
shown themselves to be of striking 
value. Decided results have been 
claimed for Escherich and ]\Ioser's 
serum, but it has not been generally 
adopted. Inasmuch as the more 
serious symptoms of scarlet fever are 
all largely due to streptococcic infec- 
tion, the theory underlying the use of 
normal serum is not irrational. At 
the present writing, however, no posi- 
tive statements can be made regard- 
ing its efificacy. 

[The value of antistreptococci 
serum is doubted and its use is 
limited. There are several conditions 
where one would not use the serum : 
1. In cases with very high tempera- 
ture. 2. In very young infants or pa- 
tients who are greatly exhausted from 
the effects of the disease. If indi- 
cated, use 20 to 40 c.c. every 4 to 6 
hours. The prophylactic dose to 
others is 10 c.c, but a single inocula- 
tion does not confer immunity, and 
immunity, when present, does not last 
over 6 months. — H. Brooker Mills.] 

More promising results have been 
obtained from serum of convalescents. 
In a recent malignant epidemic of 
scarlatina at Stockholm, convalescent 
serum was obtained from the fourth 
to the seventh week of the disease, 
and 0.5 per cent, of phenol added. It 
was then used exclusively in des- 
perate cases, with intense intoxica- 
tion, bad mental state, pulse 140 to 
160, cyanosis, fever 40° to 41° C— 
cases in which recovery would aver- 
age much less than 50 per cent. Of 
237 cases sufficiently serious to re- 



ceive serum, 195 recovered, while 25 
died in the first and 17 in the second 
week of the disease. Of the 195 
cures, 101 were very prompt. In 91 
cases of the same type who received 
no serum the mortality was 70 per 
cent. Mild cases can supply serum 
as potent as severe cases. Kling and 
Widfelt (Hygiea, Jan. 16, 1918). 

In treating severe scarlet fever 
witli convalescent serum, the blood 
was drawn from the twentieth to the 
twentj--eighth day. Serums from sev- 
eral patients were mixed, tested for 
sterility, and stored in the refriger- 
ator. The serum was injected intra- 
muscularly in the thighs in doses of 
25 to 90 c.c. (6% drams to 3 ounces), 
60 c.c. (2 ounces) being tlie usual 
dose. Commonh' a single dose was 
given, occasionally 2. Xo local or 
general disturbances followed. Nine- 
teen cases were thus treated. Quite 
constantly a fall of temperature be- 
gan two to four hours after the in- 
jection and continued gradually for 
twelve to twent}--four hours. In 
purth- toxic cases the temperature 
fell to nearly normal and tended to 
remain there. In cases with septic 
complications it rose again after the 
fall and ran a "septic" course. Weaver 
(Jour, of Infect. Dis., Mar., 1918). 

Report of favorable results in pro- 
phylaxis of scarlet fever by the use 
of a sere vaccine obtained from the 
desquamated scales of scarlet fever 
patients. Horses treated with it de- 
veloped antibodies in their serum to 
an amboceptor power of 2000. Of 40 
children immunized and allowed to 
live and sleep in the same bed with 
scarlet fever patients, not one con- 
tracted the disease. Of 25 children in 
families where there was a case of 
the disease, not one contracted it. 
The immunized children were fol- 
lowed for si.x months, and the per- 
sistent presence of the amboceptors 
confirmed. Di Cristina and Pastore 
(Pediatria, Jan., 1919). 

According to Ramond and Schultz, 
sodium salicylate possesses to a cer- 
tain degree specific properties. 



SCARLET FEVER (CRANDALL AND MILLS). 



93 



Sodium salicylate is indicated in 
scarlatina. It should be given from the 
start, but on the fifth day discontin- 
ued, and resumed from the fifteenth 
to the twentieth day, when late com- 
plications are due. The dose is about 
6 Gm. (90 grains) per day, increased 
to 8 Gm. (2 drams) or more if re- 
quired. Nocturnal exacerbations be- 
ing typical in scarlet fever, the drug 
should be continued during the night. 
At the fifteenth day the dosage need 
not be as large. Under this drug the 
fever subsides by the third day. The 
throat lesions are rapidly reduced, but 
with the recrudescence at the fifteenth 
day, may reappear in an aggravated 
form. They are rapidly controlled by 
the salicylate. The latter may abort 
late nephritis if given in time, but if 
the complication has several days' 
headway, should be given cautiously, 
lest the kidneys be unable to excrete 
it. If it can pass the kidneys the dose 
may then be augmented. On all other 
manifestations of the disease, the 
drug acts more or less as a specific. 
Ramond and Schultz (Jour, de med. 
de Paris, Sept., 1916). 

Salvarsan, and especially neosal- 
varsan, have been much lauded, but 
neither has stood the test of experience. 

[But little medicine should be 
given, but the free use of water is 
necessary. The one and only drug" 
that is usually necessary is potas- 
sium citrate in 2- to 5- grain (0.13 to 
2 Gm.) doses, or liquor potassii 
citratis, 15 to 20 minims (0.9 to 1.25 
c.c.) three times a day. Sweet spirit 
of nitre should not be given freely. 
The skin in scarlet fever is not active, 
and therefore there is no use for a 
diaphoretic ; as for diuretics, the pos- 
sibility of damaged kidneys should 
always be borne in mind. If renal 
inflammation develops, poultices ap- 
plied over the kidney region may do 
good. Make flaxseed poultice with 16 
parts flaxseed and 1 part mustard, or 



4 parts flaxseed and 1 part digitalis 
leaves. Put on every four hours dur- 
ing the day, and keep on hot for half 
an hour. For stimulation, when 
needed, caffeine sodium-benzoate in 
%-grain (0.03 Gm.) doses hypoder- 
inically is among the best. Digitalis 
and strophanthus, the latter especially 
in very young children, may be em- 
ployed by mouth. Itching is very 
troublesome during desquamation in 
scarlet fever; warm baths followed 
by cacao-butter inunctions are very 
helpful.— H. Brooker Mills.] 

As emaciation and anemia are fre- 
quent results of scarlet fever, active 
tonic treatment should be instituted 
during the convalescence, the chief re- 
liance being placed upon iron. Bash- 
am's mixture is especially indicated. 
The patient should be particularly 
protected from cold, for exposure not 
infrequently seems to precipitate 
nephritis long after its usual period of 
occurrence. 

When the depression becomes 
threatening the use of adrenalin 
sometimes proves very beneficial, as 
shown by Hutinel. The 1 : 1(X)0 solu- 
tion may be slowly injected intra- 
muscularly in saline solution, the dose 
varying with the age, from 5 to 10 
minims, repeated every hour or two. 

The blood-pressure was found in a 
series of cases to be subnormal in 25 
per cent. Pronounced arterial hy- 
potension, especially if accompanied 
by other signs of acute suprarenal 
insufficiency, should be treated by 
adrenalin. J. D. Rolleston (Brit. 
Jour, of Children's Dis., Oct., 1912). 

The writer found adrenalin very 
useful in tiding the patients past the 
danger point when the adrenals 
seemed to be suffering acutely from 
the infectious toxic process. Cam- 
phorated oil, also proved surprisingly 
effectual. P. H. Kramer (Neder- 



94 



SCHLAMMFIEBER. 



SCLERODERMA. 



landsch Tijdschrift v. Geneeskunde, 
Sept. 6, 1913). 

In the writer's service there were 
34 cases of malignant scarlet fever 
in a total of 550 cases of this disease; 
in a previous series of 833 cases there 
were 27 that terminated fatally. Re- 
covery was the rule in destructive 
lesions in the throat; the defects in 
the tissues were filled in time and no 
operation was required. Hutinel 
(Arch, de med. des cnfants, Feb. 1915). 
Floyd M. Cr.and.all, 

New York, 

AND 

H. Brooker Mills, 

Philadelphia. 

SCHLAMMFIEBER. -This name 
was applied to a form of acute infectious 
jaundice which occurred among young 
subjects who had worked in the districts 
of Breslau that had been recently flooded. 
It is not entitled to classification as a 
disease, since it corresponds in every way 
with acute infectious jaundice (Weil's dis- 
ease), treated on page 394 of the sixth 
volume of the present work. 

SCLERODERMA.-DEFINITION. 

— A disease characterized by induration 
of the skin, and at times of the sub- 
cutaneous tissues, which sometimes pro- 
gresses to complete atrophy of these 
tissues. 

VARIETIES.— Three main varieties of 
scleroderma are recognized: the diffuse, 
which is generalized or limited to certain 
areas; the circumscribed, or morphea, 
which appears in spots; and sclerodac- 
tyly, which is limited to the hands. 

SYMPTOMS.— In the diffuse form, 
after a series of prodromic symptoms, 
sensations of chilliness or heat, pruritus, 
and pain in the muscles and articulations, 
the tissues becoming thickened, stifif, and 
hard, and appear edematous. The skin 
is cold and whitish, contracted, and some- 
times painful. The face and the upper 
part of the body may be the only parts 
aflfected, but the entire body becomes in- 
volved. The skin is, as it were, glued to 
the skeleton, the fingers and toes being 
thin and stifif or hooked. A variable 
amount of pigmentation is usually pres- 
ent in well-developed cases. Gangrene 



is sometimes observed, constituting the 
mutilating form. 

In the circumscribed variety, the mor- 
phea of Erasmus Wilson, the affected 
spots are limited in area, the spots being 
flat or raised, oval or rounded. Their 
color varies from a light pink to a pale 
or dark violet, and undergoes changes 
which ultimately give the lesion a 
characteristic aspect: a whitish-brown 
squamous center surrounded by a bluish 
or lilac pigmented border, or ring. They 
are seldom painful, though pruritus is 
sometimes complained of. The spots, of 
which there are generally but two or 
three, are usually located upon the neck, 
the chest, the abdomen, the arms, or 
the thighs. These spots gradually fade 
away, but occasionally cicatrices are left 
to mark the location of the lesions. The 
prognosis in this form is favorable. 

In sclcrodactyly the third phalanx be- 
comes atrophied and its tissues, including 
the nail, are partially destroyed by ab- 
scess. The flexor tendons are contracted 
and give the finger the appearance of an 
angular hook by flexing the first phalanx 
upon the second. Here also the skin is 
hard, contracted, adherent to the bones, 
and lilac in color. The prognosis is 
necessarily unfavorable, owing to the 
mutilations caused by the disease. 

DIAGNOSIS.— The only condition with 
which scleroderma can be easily con- 
founded is leprosy, but the tubercles of 
the latter disease, the broad dissemina- 
tion of the skin lesions, the nasal dis- 
order, the character of the ulcerations, 
and the disturbances of sensation usually 
facilitate its recognition. 

Osier observes that diffuse scleroderma 
must sometimes be distinguished from 
brawny, solid edema, met with at times in 
patients with long-standing renal or car- 
diac disease, in which there is induration 
following chronic dropsy. In scorbutic 
sclerosis there may be parchment-like 
immobility of the skin, due to extensive 
subcutaneous hemorrhages, involving the 
muscles. 

During the stage of swelling it may 
resemble myxedema. In Raynaud's dis- 
ease the infiltration, pigmentation, and 
extreme cyanosis are not wholly unlike 
those of scleroderma. The increase of 



SCOPARIUS AND SPARTEINE (WITHERSTINE). 



95 



pigment may suggest Addison's disease, 
since the bronzing may be extreme. 

ETIOLOGY AND PATHOLOGY.— 
Scleroderma is an angiotrophoneurosis, 
most frequently observed among neurotic 
subjects and often in connection with 
the rheumatic diathesis. It may appear at 
any age, but chiefly in early adult life, 
and is more prevalent among women than 
men. The neurotic influence, however, 
does not account for all cases, nerve- 
changes being wanting in the majority. 
Exposure to cold and wet, rheumatism, 
nerve shocks, menstrual disorders, trau- 
matism, etc., are named as causes. 

Kaposi notes that the lesions follow, 
to a degree, vascular distribution. The 
morbid changes peculiar to scleroderma 
include an endoperiarteritis, which may 
be traced to various structures: the mus- 
cles, the myocardium, the uterus, the 
lungs, and the kidneys particularly. The 
sclerosis would thus seem to be a result 
of the vascular disturbances, through 
impaired nutrition of the aflfected areas. 

The chief changes in the skin, according 
to Schamberg, are an increase and con- 
densation of the connective tissue in the 
corium and the subcutaneous tissue, an 
increase in the elastic tissue, and a dimi- 
nution in the caliber of the blood-vessels. 
Later atrophy of the subcutaneous tissues 
occurs. 

Reines reported 13 cases which seemed 
to confirm the connection between sclero- 
derma and tuberculous infection. 

Of 5 cases of diffuse scleroderma exam- 
ined by Whitehouse, 3 gave a strongly 
positive Wassermann reaction, 1 a faintly 
positive and 1 a negative reaction. 

According to Ravogli, 1917, the under- 
lying factor in the disease is a disturbance 
of equilibrium of the internal secretions of 
the adrenals, thyroid, etc., while exposure 
is often the determining factor. Criado, 
1918, obtained improvement in one case by 
adrenal administration, and made the sug- 
gestion that adrenin be also used locally. 

PROGNOSIS.— The prognosis is ex- 
ceedingly unfavorable as regards cure. 
The disease usually persists throughout 
life. Improvement occurs in quite a third 
of the cases. In adults Lewin and Heller 
report 16 per cent, of cures, and 31 per 
cent, in children under 15 years of age. 



TREATMENT.— The treatment con- 
sists in nutritious diet, good hygienic 
surroundings, iron, and codliver oil in 
ascending duses (the latter up to 10 table- 
spoonfuls per day); sodium salicylate; ex- 
ternally, steam baths, mud baths, mer- 
cury (by inunction), galvanism, and mas- 
sage. The most recent remedy is thyroid 
gland; but, according to Osier, it is not 
of much value. Brocq recommends elec- 
trolysis, at first at comparatively short 
intervals; then, when amelioration is 
manifest, at much longer intervals. Elec- 
trolysis does not act by destructive action, 
but at a distance, influencing even patches 
not touched. Philippsohn obtained excel- 
lent results by the administration of 
salol, in doses of about 7 to 15 grains 
(0.45 to 1 Gm.), three or four times daily. 

S. and W. 

SCLEROSIS. See Index. 

SCOLIOSIS. See Spine, Diseases 
AND Injuries of. 

SCOPARIUS AND SPARTE- 
INE. — Scoparius, N. F. (spartium, 
broom, broom-tops, besom), is the 
dried tops of Cytisus scoparius (fam., 
Leguminos?e), a densely growing 
shrub indigenous to Europe and ad- 
jacent Asia, and sparingly naturalized 
in sandy soil in North America. Its 
long, slender, erect, and tough twigs 
are arranged in large, close fascicles 
which lie parallel with and close to 
one another, and have a peculiar odor 
wdien bruised, and a disagreeably bit- 
ter taste. The quality of the drug 
deteriorates with keeping, the pecu- 
liar odor of the recently dried drug 
being partially or completely lost. 

Broom contains two active princi- 
ples, sparteine and scoparin. 

Sparteine (Cir,H26N2) is a trans- 
parent, oily liquid, colorless when 
fresh, but turning brown on exposure, 
having an odor resembling that of 
aniline, and a very bitter taste. Spar- 
teine is heavier than water. It is but 



96 



SCOPARIUS AND SPARTEINE (WITHERSTINE). 



slightly soluble in water, but readily 
dissolves in alcohol, ether, and chloro- 
form, and is insoluble in benzene and 
benzin. Sparteine contains the car- 
diac properties of scoparius. 

The official sulphate of sparteine is 
prepared by dissolving- 10 parts of re- 
cently distilled sparteine in 40 parts 
of diluted (10 per cent.) sulphuric 
acid, and allowing the solution to 
crystallize in a warm place. It should 
be kept in well-stoppered, amber-col- 
ored vials. Sparteine sulphate occurs 
as colorless, rhomboidal crystals, or 
as a crystalline powder, odorless, but 
having a slightly salty and somewhat 
bitter taste, soluble in 1.1 parts of 
water, 2.4 parts of alcohol, but in- 
soluble in ether and chloroform. It 
is hygroscopic, and its aqueous solu- 
tion has an acid reaction. 

Scoparin (C21H22O10) is a gluco- 
side, occurring in pale-yellow crystals, 
without odor or taste, and soluble in 
alcohol, alkalies, and in hot water. It 
probably represents most of the diu- 
retic properties of scoparius. 

PREPARATIONS AND DOSES. 
— The only official preparation is : — 

Sparteincc sulphas, U. S. P. (sparte- 
ine sulphate). Dose, y^ to 2 grams 
0.008 to 0.13 Gm.). 

Unofficial but serviceable prepara- 
tions are : — 

Scoparius, N. F. (broom-tops). 
Dose, 15 to 60 grains ( 1 to 4 Gm.). 
usually in decoction. 

Decoctum scoparii (decoction of 
broom, made by adding ^ ounce — 
16 Gm. — to 1 pint — 500 c.c. — of water, 
and boiling down to /^ pint — 250 
c.c). Dose, 1 ounce (30 c.c.) to be 
taken every three hours, 

Fluidextractum scoparii, N. F. 
(fluidextract of broom). Dose, 15 to 
30 minims (1 to 2 c.c). 



Infusum scoparii, Br. P. (infusion 
of broom, made by adding 2 ounces — 
60 Gm. — of dried and bruised l)room- 
tops to 20 ounces — 600 c.c. — of boil- 
ing distilled water; infusing in a 
covered vessel for fifteen minutes and 
straining). Dose, 1 ounce (30 c.c.) 
every three hours. 

Scoparin (the glucoside). Dose, 8 
to 15 grains (0.5 to 1 Gm.). 

PHYSIOLOGICAL ACTION. — 
Internally broom, in large doses, ex- 
cites vomiting and purging, and in 
smaller doses increases the urinary 
output. Sparteine acts upon the 
heart as a stimulant or tonic like 
digitalin, wiiile scoparin exerts its 
action upon the kidneys. Sparteine 
has a decided elTect upon the nerves 
and spinal cord, lowering reflex ac- 
tion, paralyzing motor nerves, reduc- 
ing the electrical excitability of the 
vagus and, finally, causing death by 
paralysis of respiration, both as a re- 
sult of its action upon the center and 
upon the respiratory muscles. 

In its action upon the circulation 
sparteine, according to most observ- 
ers, causes a transient rise in ar- 
terial pressure, followed by a longer 
period of diminished vascular tension. 
Laborde, however, claims that spar- 
teine has no influence on the blood- 
pressure. Small doses slow the heart 
for a short period and then accelerate 
it, the volume of the pulse being sim- 
ultaneously increased. Large doses 
cause marked depression of the car- 
diac muscle, and of the vagus. The 
heart responds to its action in about 
twenty to thirty minutes, and the 
efifect continues for from six to eight 
hours. 

No cumulative action has been ob- 
served. When taken regularly for 
several weeks, the effects continue for 



SCOPARIUS AND SPARTEINE (WITHERSTINE). 97 

several days after discontinuing the solved in water with a trace of am- 

remedy. monia, or in a mixture of 1 part of 

In its action on the muscles, D. glycerin and 3 parts of water, given 

Cerna demonstrated that sparteine hypodermically. 

causes a brief period of increased Sparteine is pre-eminently a heart 

muscular irritability, that it augments tonic and heart regulator, rapid in its 

reflex action by a direct influence action, certain in its effects, and pro- 

upon the spinal cord, this increase be- ducing a regulation of the heart's 

ing followed by a subsequent depres- pulsations in more ways than one. 

sion, that it gives rise to convulsions If the pulse rate is below normal, it 

of a spinal origin and generally will cause acceleration, but if above 

tetanic, that it causes a primary in- normal, it will bring it down, 

crease in the rate and force of the Laborde calls it the "cardiac met- 

heart's action by a direct influence ronome." In weak and irregular 

upon the heart, the increase being heart Germain See advises doses of 

soon followed by a decrease, due to from ^ to % grain (0.016 to 0.01 

direct cardiac action and stimulation Gm.) every four hours. In heart- 

of the cardioinhibitory centers ; it aug- failure, the result of mitral disease, it 

ments the blood-pressure by an action gives the best results. In valvular 

upon the heart, and also by stimulat- disease, with defective compensation, 

ing the central vasomotor system ; the small doses are apparently more efifi- 

arterial pressure subsequently de- cacious than large ones. Shoemaker 

clines, owing to paralysis of the vaso- has found sparteine of service in 

motor system and a direct depressant cases of enfeebled cardiac action from 

action upon the cardiac musculature, structural lesions, and also where the 

It is claimed that sparteine strongly innervation of the heart was markedly 

and promptly reduces the size of the disturbed. In mitral disease it is 

heart. particularly valuable, even in the ad- 

THERAPEUTIC USES.— In re- vanced stage, when dilatation has be- 
nal insufficiency with deficient urin- gun. In cases of dyspnea, palpitation, 
ary secretion, due to lowered* arterial and cardiac debility, due to fatty de- 
tension, scoparius yields good results ; position around the heart, sparteine 
also in the edema, or dropsy, accom- is satisfactory. In dilatation due to 
panying heart lesions. It is con- valvular disease sparteine may be 
traindicated in the acute stage of given hypodermically. In functional 
inflammation of the lungs, heart, or cardiac disease, the result of exces- 
kidneys, but in the subacute or sive bodily or mental labor, anxiety, 
chronic stage it may be used w^ith and in "tobacco heart," sparteine will 
advantage. In hydrothorax and as- yield gratifying results. In chronic 
cites occasional doses of compound parenchymatous nephritis sparteine 
jalap powder may be combined with will aid in the elimination of urea 
it to advantage. and thus prevent uremia. In valvular 
Scoparin has been used as a diu- cardiac disease, due to acute articular 
retic in doses of from 8 to 15 grains rheumatism, cardiac dilatation with 
(0.5 to 1 Gm.) by the mouth, or ^ failing compensation, chorea asso- 
to 1 grain (0.03 to 0.06 Gm.) dis- ciated with endocarditis, exophthal- 

8—7 



98 SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 

mic goiter, etc., Cerna has obtained scopola (or scopolia) is derived from 

good results from the use of si)ar- Scopoli, an Italian who was professor 

teine. In morphine addictions spar- of botany in Pavia about the middle 

teine is useful in supporting the heart of the eighteenth centur}^ 

and system during the withdrawal of Though discovered, the one in hyo- 

the drug. In postoperative suppres- scyamus and the other in scopola, 

sion of urine, postanesthetic nausea, hyoscine and scopolamine are identi- 

and operative shock, Pettey places cal chemically. Most of the drug be- 

great faith in sparteine, but insists ing obtained from scopola rather than 

that the dose be at least 2 grains hyoscyamus, the term scopolamine is 

(0.13 Gm.), repeated every two to six often given preference, and in many 

hours, when the effect of the remedy European countries it is the only 

is to be assured. Hysterical excite- appellation used. 

ment is, in many cases, amenable to Officially, that is to say, from the 

sparteine sulphate. standpoint of the United States 

C. Sumner Witherstine, Pharmacopoeia, scopolamine and hyo- 

Philadelphia. seine are identical in all respects. A 
slight distinction is, however, some- 

SCOPOLAMINE (HYOSCINE) times made between the two sub- 

AND SCOPOLA. — Scopolamine, or stances with respect to their optical 

hyoscine (C17H21NO4), is an alkaloid properties, scopolamine being taken 

obtained from various plants of the to refer to a completely levorotatory 

family Solanacese, including Atropa specimen of the alkaloid, i.e., one 

belladonna, Datura straniomum, Hyo- which rotates the plane of polarized 

scyamus nigcr, and Scopola carniolica. light as far to the left as this par- 

The last-named plant is an herb ticular chemical compound is capable 

growing in the eastern Alps, Car- of doing it, and is composed exclu- 

pathian Alountains, and neighboring sively of levorotatory molecules, 

regions, and contains about 0.6 per while hyoscine is taken to refer to 

cent, of total mydriatic alkaloids, in- any specimen ranging between the 

eluding 0.06 per cent, of scopolamine, completely levorotatory and the in- 

Scopola japonicas is another species of active, the latter being a mixture in 

the plant, growing in Japan, and con- equal parts of levorotatory and dex- 

taining the same principles as the trorotatory molecules. The optically 

European scopola. In these two inactive variety of hyoscine is termed 

plants, scopolamine is present in atroscine. Levoscopolamine, imder 

larger amount than in the other mem- the influence of light, is gradually 

bers of the solanaceous group, the transformed into atroscine, thereby 

next being hyoscyamus, which, in its suft'ering some reduction in its pcriph- 

total alkaloidal content of 0.08 to 0.15 eral nervous effects, i.e., mydriasis, 

per cent., contains 0.02 to 0.0375 per vagal paralysis, arrest of secretion, 

cent, of scopolamine (Kraemer). The etc. For ordinary purposes, however, 

histological structure of the scopola scopolamine and hyoscine are gener- 

rhizome, which is the part of the plant ally considered equivalent. Various 

used in medicine, closely resembles preparations that have, in the past, 

that of belladonna root. The name been termed hyoscine have consisted 



. SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 99 

merely of a more or less impure ally administered hypodermically, 

scopolamine. though oral use is also feasible, the 

PREPARATIONS AND DOSE, alkaloids being absorbed with almost 

— Scopolamincc hydrobromidnm, U. S. equal certainty, though less rapidly, 

P. (scopolamine or hyoscine hydrobro- than when injected. Solutions of the 

mide) [Ci7HoiN40.HBr-)-3H20], oc- alkaloids deteriorate quickly on keep- 

curring in colorless rhombic crystals, ing, but Straub has found that by 

sometimes of large size, with an acrid, adding to them 5 to 20 per cent, of 

slightly bitter taste, and slightly efflores- mannite — a harmless substance which 

cent. It is soluble in 1.5 parts of may be injected into the tissues with- 

water, in 16 parts of alcohol, and in out fear of causing local irritation — 

750 parts of chloroform. It should be they may be kept for an indefinite 

kept in amber-colored vials. Dose, ^^o period without loss of activity, 

to i/so grain (0.0002 to 0.001 Gm.). PHYSIOLOGICAL ACTION.— 

The following preparations were for- Nervous System. — Scopolamine (hyo- 

merl}^ official: — seine), like atropine, produces distinct 

Scopola, U. S. P. VIII (scopola), effects on both central and peripheral 

the dried rhizome of Scopola carnioHca, nervous structures. Its central ef- 

required to yield not less than 0.5 per fects differ in quality, however, from 

cent, of mydriatic alkaloids. Dose, j/i those of atropine, consisting chiefly of 

grain (0.045 Gm.). a pronounced depression of the psy- 

Fluidcxtractiim scopolcc, U. S. P. chic and motor centers of the brain, 

VIII (fluidextract of scopola), contain- the result being a hypnotic effect, 

ing 0.5 Gm. of mydriatic alkaloids in which passes, if the dose be large 

each 100 c.c. Dose, 1 minim (0.06 c.c). enough, into narcosis. The electrical 

Extractum scopolcc, U. S. P. VIII excitability of the brain is reduced, 

(extract of scopola), made by evap- The human subject to whom scopola- 

orating the fluidextract, and required mine (hyoscine) has been adminis- 

to contain 2 per cent, of alkaloids, tered becomes quiet and sluggish. 

Dose, % grain (0.01 Gm.). because of early depression of the 

Hyoscincc hydrobromiduni, U. S. P. motor centers, and soon falls asleep. 

VIII (hyoscine hydrobromide), chem- At times these effects appear, after a 

ically identical with scopolamine hydro- short period of latency, with marked 

bromide. Same dose. suddenness, and their intensity may 

INCOMPATIBILITIES. — Hyo- prove alarming to nearby persons, 

seine and scopolamine are incom- Occasionally sleep is preceded by a 

patible with alkalies, tannic acid, short period of excitement, which 

potassium permanganate, iodides, and may either represent an attenuated 

salts of some of the heavy metals, manifestation in scopolamine of the 

such as mercury bichloride, silver delirifacient action of atropine or be 

nitrate, lead acetate, and ferric due to the presence of the convulsive, 

chloride. highly toxic alkaloid apoatropine as 

MODES OF ADMINISTRA- an impurity. (This impurity may be 

TION. — Scopola, when used, is ad- detected by adding a little dilute 

ministered by mouth. The alkaloids potassium permanganate solution to 

scopolamine and hyoscine are gener- the solution of scopolamine, the violet 



100 SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 

color changing- to a yellow-brown if Respiration. — The effect on the re- 
apoatropine is present.) In excessive spiratory is the same as that on the 
amounts scopolamine induces either vasomotco" center. Respiration is de- 
coma or — probably only if impure — a pressed by full doses, 
condition of sleep and unconscious- Eye. — Scopolamine, instilled in the 
ness interrupted at more or less fre- eye, acts like atropine, but more 
quent intervals with a delirious rapidly and in an amount about four 
outburst or low, muttering delirium, times less. A 0.2 per cent. (1 grain 
Scopolamine acts upon the spinal cord to the ounce) solution will dilate the 
as on the brain, a more or less com- pupil in ten to thirty minutes, and 
plete depression of the spinal reflexes shortly thereafter induce paralysis of 
being, therefore, characteristic, espe- accommodation. These effects are 
cially after large doses. due to paralysis of the oculomotor 

The peripheral nervous effects of nerve endings in the constrictor mus- 
scopolamine are essentially those of cle of the iris and the ciliary muscle, 
atropine, consisting of depression or respectively. The drug does not in- 
paralysis of the terminals of the vago- crease intraocular tension. Its effects 
sacral autonomic system and of the on the eye pass off more rapidly than 
secretory nerves. The effects of atro- those of atropine, viz., in three to five 
pine on the pupils, involuntary mus- days. The pupil regains its normal 
cles in general, and secretions are diameter in about seventy hours, and 
reproduced, though the dosage of the power of accommodation is re- 
scopolamine for simple hypnotic pur- covered in four days (Oliver). A 
poses being, as a rule, less than the slight stinging or feeling of astrin- 
customary full dose of atropine, these gency in the conjunctiva may be ex- 
effects are not as often noticed as perienced after its instillation, 
w^ith atropine. Although the ability Secretions. — Scopolamine inhibits, 
of scopolamine to paralyze the end- like atropine, those secretions which 
ings of the vagus nerves in the heart, are under nervous control, paralyzing 
and therefore to accelerate heart ac- the endings of the secretory nerves 
tion is not questioned, many have distributed to them. Kamensky wit- 
clinically noticed slowing of the heart nessed arrest of the salivary, gastric, 
after its administration. This is pancreatic, and sweat secretions by 
doubtless either an indirect eft'ect. the drug in laboratory animals; the 
the result of motor inactivity, or effect on the pancreas took place 
due to admixture of some cardiotoxic much later than that on the other 
impurity. secretions. 

Circulation.— Or d\n2ir\\y no cardiac ABSORPTION AND ELIMINA- 

acceleration is induced by scopola- TION. — Scopolamine is readily ab- 

mine, the dose used being too small, sorbed from mucous membranes. It 

The alkaloid differs from atropine, in is more rapidly destroyed in the sys- 

that it has no stimulating effect on tern or excreted than atropine, and 

the vasomotor center. In large doses, its eff'ects are of correspondingly 

it depresses this center from the shorter duration. 

start, a corresponding reduction in UNTOWARD EFFECTS AND 

the blood-pressure taking place. POISONING. — The dose of scopola- 



SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 



101 



mine borne without unpleasant re- 
sulting symptoms seems to vary 
considerably in different individuals. 
Occasionally somnolence and dizzi- 
ness appear in ophthalmic use of the 
drug". In persons with an idiosyn- 
crasy therapeutic doses may. in addi- 
tion, produce effects similar to those 
of beginning atropine intoxication, 
viz., dryness of the mouth, flushing 
of the skin, mydriasis, and difficulty 
in swallowing. The dose ordinarily 
toxic lies between ^Xoo and Yso grain 
(0.0006 and 0.002 Gm.). From doses 
larger than are required for thera- 
peutic effects there result, in addition 
to the symptoms already mentioned, 
ataxia, indistinct speech, unconscious- 
ness, perhaps followed by delirium 
and hallucinations and an accelerated 
feeble pulse. 

Even therapeutic amounts at times 
produce alarming effects. Thus, cases 
of collapse from ^,,0 grain (0.0006 
Gm.) have been reported, with pro- 
nounced muscular weakness, flushing 
of the face, a hard, rapid pulse, noisy, 
rapid breathing, twitching of the 
hands, and cool perspiration. Col- 
lapse has also been recorded from 
ophthalmic instillation of the drug. 
M. L. Foster has reported the case of 
a young man in whom four instilla- 
tions of 1 drop of a 0.2 per cent, solu- 
tion of scopolamine hydrobromide 
had been made in each eye at ten- 
minute intervals — total amount about 
Yqo grain (0.001 Gm.). Fifteen min- 
utes after the last instillations dizzi- 
ness appeared, followed by dryness of 
the throat, nausea and attempts to 
vomit, flushing of the face, motor 
weakness, and tachycardia (over 160 
a minute), attaining their maximum in 
about two hours ; the patient became 
cyanotic, actively delirious, and had 



what appeared to be toxic convul- 
sions. Rapid recovery thereafter took 
place under morphine and whisky. 
S. W. Morton has recorded a case of 
poisoning by Y-, grain (0.0008 Gm.) 
of hyoscine hydrobromide, with in- 
ability to swallow and complete pa- 
ralysis of the soft palate and upper lip. 
In an ataxic man Gibbs witnessed 
poisoning, with delirum and convul- 
sions, from y^Q grain (0.0012 Gm.). 
R. A. Morton, after instillation of 2 
drops of 1 per cent, hyoscine hydro- 
bromide into the eyes of an adult, 
observed muscular relaxation and un- 
consciousness lasting four hours, fol- 
lowed by delirium lasting two hours, 
and then sleep lasting one and one- 
half hours. F. Krauss observed excite- 
ment lasting over seven hours in a 
girl of 15, who had instilled 2 drops 
of a 2-grain to the ounce solution in 
each eye before retiring. 

Fatal results from scopolamine in- 
toxication have been rare. Bastedo 
has met with fatal collapse from %o 
grain (0.0012 Gm.) in an alcoholic 
man with pneumonia. On the other 
hand, he witnessed recovery from ^5 
grain (0.0024 Gm.) in an alcoholic 
woman verging on delirium tremens. 
In each of these cases morphine had 
preceded the hyoscine. Recoveries 
from ^ and even 3^ grain (0.03 Gm.) 
of hyoscine in cases subsequently re- 
ceiving more or less therapeutic at- 
tention have been reported. 

Treatment of Poisoning. — If the 
drug has been taken by the mouth, 
the stomach should be evacuated with 
emetics or the stomach-tube. Tannic 
acid or Lugol's solution may precede 
this, if they are immediately at hand 
and the case is seen early. As 
physiological antidotes, pilocarpine, 
J4 grain (0.015 Gm.), and strychnine, 



102 



SCOPOLAMINE (HVOSCINE) AND SCOPOLA (SAJOUS). 



Vso to 1/20 grain (0.002 to 0.003 Gm.), 
or caffeine sodiobenzoate, 5 grains 
(0.3 Gm.), or hot, strong coffee 
should be given. Where delirium re- 
places the unconsciousness or coma, 
sedatives such as chloral hydrate, 10 
grains (0.6 Gm.) ; tincture of opium, 
15 minims (1 c.c), or morphine, % 
grain (0.01 Gm.) hypodermically, may 
be availed of. Electricity and other 
excitants of the skin surface may be 
used, as in opium poisoning, to com- 
bat narcosis. In cases with pro- 
nounced circulatory depression, digi- 
talis, epinephrin, ether, ammonia 
preparations, etc., should be freely 
used. Artificial respiration, external 
heat, skin frictions, and oxygen in- 
halations are other measures that 
may prove of value. 

THERAPEUTICS as Sedative to 
the Central Nervous System. — In in- 
somnia due to mental excitement, a 
persistent wandering of the mind 
from one subject of thought to an- 
other preventing sleep, and in the 
insomnia of neurasthenia, scopola- 
mine (hyoscine) in small doses, such 
as %oo grain (0.0002 Gm.), is of value 
where other milder hypnotics fail or 
have to be discontinued because of a 
tendency to habit formation. Though 
less certain in its effect than chloral 
hydrate, scopolamine has advantages 
over the latter in being of small bulk, 
non-irritating, and well suited for 
hypodermic use. According to Wind- 
scheid, as little as %5o grain (0.0001 
Gm.) is capable of causing somno- 
lence. In sleeplessness due to pain, 
scopolamine is ineffectual when given 
alone, but if combined with morphine 
in small amounts proves useful, in- 
tensifying the action of the latter. 

In the insomnia due to motor ex- 
citation, scopolamine is particularly 



effective. This applies in delirum 
tremens, in which, e.g., Lambert 
recommends a combination of sco- 
polamine hydrobromide, ^/|oo grain 
(0.0006 Gm.), with apom^orphine hy- 
drochloride, %o grain (0.003 Gm.), 
and strychnine sulphate, fvQ gram 
(0.002 Gm.), administered hypoderm- 
ically. Liepelt found it more active 
in this condition, if properly applied, 
than either chloral hydrate or mor- 
phine. In the delirium of infectious 
diseases, including pneumonia, ty- 
phoid fever, septicemir, etc., scopola- 
mine is of value, especially where a 
feeble, dilated heart or pronounced 
circulatory impairment, e.g., in alco- 
holics, contraindicate the use of 
chloral hydrate. For this purpose it 
should be used in moderate dosage — 
yi50 to 1/100 grain (0.0004 to 0.0006 
Gm.). If the first dose proves totally 
ineffective, or the delirium, as oc- 
casionally happens, is increased in- 
stead of diminished, the drug should 
not be further used. Similar consid- 
erations apply in the insomnia of 
infectious diseases. In pronounced 
restlessness in neurasthenia, scopo- 
lamine may also be used with 
advantage. 

In acute maniacal states the use 
of scopolamine has, to a considerable 
extent, replaced that of morphine. 
According to H. S. Noble, in the re- 
curring forms of insanity, maniacal 
attacks can often be averted with it. 
Such patients, at the first intimation 
of approaching excitement, are given 
an active cathartic, usually mercurial, 
followed by 1/100 to 1/75 grain (0.0006 
to 0.0008 Gm.) of scopolamine hydro- 
bromide morning and evening, rarely 
oftener. Little or no tolerance to the 
drug is established. In agitated 
melancholia Doerner found scopola- 



SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 103 

mine often to bring about quietude scopolamine, given half an hour be- 
when all other means had failed. The fore retiring, of great value in 
effect comes on rapidly and lasts from controlling the spasmodic cramps 
three to ten hours, according to the sometimes experienced in the lower 
dose given. Insane patients are often extremities on retiring, or upon 
more resistant to the effects of sco- stretching in the morning. The same 
polamine than others, doses of %4 author successfully employed ^^s 
grain (0.001 Gm.), or even more, be- grain (0.0008 Gm.) at night to arrest 
ing sometimes necessary ; on the excessive seminal emissions. Higier 
other hand, doses as small as ^-jO found the drug valuable in pruritus 
grain (0.00025 Gm.) are sufficient in of all kinds, except diabetic. It has 
some instances. The absence of un- also been used with benefit in 
pleasant after-effects is a marked ad- hiccough. 

vantage of this drug. In the tremor of paralysis agitans 
Among other nervous conditions in and in senile or alcoholic tremor, 
which scopolamine may be availed of scopolamine yields prompt, though 
are status epilepticus, chorea, hyster- not always lasting, effects. It may 
ical convulsions, and the convulsions be used in daily doses of %4o to /42o 
of cerebrospinal meningitis. Higier, grain (0.00025 to 0.0005 Gm.), hypo- 
in a case of obstinate chorea occur- dermically, in these conditions, and 
ring in pregnancy, was able to control may be given for a long period with- 
the movements by giving a %o-grain out habituation or detrimental effect. 
(0.001 Gm.) dose daily for a week. It has also been recommended in 
In nervous asthma, the same author multiple sclerosis. 

had good results from the adminis- In the night-sweats of pulmonary 

tration of %5o to %25 grain (0.00025 tuberculosis and in lead colic scopo- 

to 0.0005 Gm.) subcutaneously at the lamine has also been used, with 

time of the attack, together with j^artial success. 

smaller doses during the intervals as For its use during withdrawal of 

prophylactic. In attacks of hystero- morphine from habitues, the reader is 

epilepsy Nagy usually obtained seda- referred to the article on Opium 

tion in five to twenty minutes by Habit. 

means of an injection of %4 grain As Mydriatic and Cycloplegic. — 
(0.001 Gm.) of the drug. In tri- For refraction purposes scopolamine 
geminal neuralgia with attacks of presents certain advantages over atro- 
muscular contracture, Pont procured pine, and is even preferred to the 
relief of pain and diminished fre- latter for routine use by some spe- 
quency and duration of the attacks cialists. Two instillations of a drop 
of contracture by giving daily injec- each of a 1-grain (0.06 Gm.) to the 
tions, either into the cheek at the ounce (30 c.c.) solution of scopola- 
painful spot or into the arm, of %-2o mine hydrobromide at an interval of 
grain (0.0002 Gm.) of scopolamine half an hour are sufficient to produce 
hydrobromide, four days' treatment complete mydriasis and cycloplegia 
being alternated with rest periods of in less than an hour after the first in- 
equal duration. Noble found ''/120 to stillation. Even a 1 in 1000 solution 
Yioo grain (0.0005 to 0.0006 Gm.) of is usually sufficient, especially if the 



104 



SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 



patient is required to instill it on the 
evening- before and the morning' of 
the day of consultation. The myd- 
riasis and likewise the paralysis of 
accommodation pass off, according to 
the amount of drug used, individual 
sensitiveness, etc., in from two to 
four days, thus markedly shortening 
the period of disability experienced as 
compared to atropine. Pressure over 
the lower canaliculus after instillation 
is recommended to minimize the pos- 
sibility of constitutional effects by 
preventing drainage of the drug into 
the lachrymal passages and nasal 
cavities, whence it is more rapidly 
absorbed. 

In inflammatory infections of the 
eye, scopolamine is held to be equally 
as valuable, or more valuable, than 
atropine, and it is said not to increase 
intraocular tension. In rheumatic or 
syphilitic iritis, it may be combined 
with or substituted for atropine in 
instillations, and may also, with ad- 
vantage, be given hypodermically at 
night to relieve pain. In plastic iritis 
scopolamine acts very energetically, 
often removing synechise, which atro- 
pine had failed to influence (Raehl- 
mann). In uveitis (serous cyclitis), 
scopolamine may be used in the ab- 
sence of increased intraocular tension 
(De Schweinitz). It may also be 
substituted for atropine in sympa- 
thetic ophthalmitis. 

MORPHINE-SCOPOLAMINE 
ANESTHESIA.— The first report on 
anesthesia produced by a combina- 
tion of morphine with scopolamine 
was made in 1900 by Schneiderlin, an 
alienist, who, having used the drugs 
simultaneously for sedative purposes 
in restless, insane patients, with sat- 
isfactory results, proceeded to employ 
them to induce surgical anesthesia in 



demented cases. The procedure is 
based chiefly on synergistic action of 
the two drug's as narcotics. Although 
the antagonism between them in cer- 
tain of their other effects might be 
thought of marked advantage, per- 
mitting the use of large doses with 
the exclusive view of causing narcosis 
and eliminating apprehension of un- 
pleasant side effects, this is true only 
to a slight degree, the opposite effects 
of the drugs on the pupil and heart 
rate having but little value, except as 
indications of the relative degree of 
action of the drugs in the individual 
case. 

The experiences of Terrier, E. Ries, 
A. C. Wood, W. Wayne Babcock, 
and others, have shown that by sub- 
cutaneous injection of scopolamine 
and morphine alone, without any in- 
halation anesthetic, a satisfactory 
surgical anesthesia can, in many 
instances, be obtained. This is es- 
pecially the case in the aged, debili- 
tated, and cachectic. The young- and 
robust, on the other hand, are re- 
sistant and show a tendency to 
excitement and delirium under scopo- 
lamine, which largely unfits them for 
this form of anesthesia. Babcock, 
substituting in young adults, for mor- 
phine and scopolamine (or adding to 
them) apomorphine, or an enema 
containing Hoffman's anodyne, alco- 
hol, and sometimes paraldehyde, has 
found that one may produce general 
anesthesia in most persons over 18 
years of age without resort to in- 
halation of ether or chloroform. The 
procedure proved very satisfactory — 
often giving results superior to any 
other form of anesthesia — in opera- 
tions upon the head, neck, respiratory 
system, and spinal column. In ab- 
dominal and rectal operations, on the 



SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 105 

other hand, and to some extent in of the inhalation anesthetic, respira- 

operations on the hands and feet, it tion is quiet and regular, and during 

was found inferior owing to failure the operation there is no vomiting or 

to abolish muscular rigidity and obstruction to breathing from fluid in 

reflexes. the air-passages. While the pulse 

Morphine-Scopolamine Preliminary may be accelerated by the scopola- 

to Inhalation Anesthesia. — In spite of mine, its quality remains good. The 

the numerous advantages of exclusive patient is able, where the part oper- 

narcotic anesthesia, where applicable, ated upon permits, to take water or 

the procedure is, in general, accorded even food shortly after awakening 

only a small field of application be- without nausea or vomiting. The 

cause of the special care required to procedure is especially valuable in 

avoid serious respiratory depression — neurotic subjects, and in patients with 

both during and for some time after organic disease of the respiratory 

the operation by the narcotics given — tract. A much larger dosage is re- 

especially the morphine, and the rela- quired in alcoholic, strong men than 

tively high mortality which has fol- in aged persons, and in the female 

lowed its application in unskilled sex. 

hands. Injection of morphine and According to Biirgi, substitution of 

scopolamine in smaller amounts be- pantopon (omnopon) for the mor- 

fore anesthesia by ether or chloro- phine in the morphine-scopolamine 

form, on the other hand, is considered combination is of advantage, in that 

less dangerous and looked upon with the respiratory center is less influ- 

much more favor. The dosage ranges enced and the likelihood of vomiting, 

from % grain (0.01 Gm.) of morphine A %-grain (0.04 Gm.) dose of panto- 

and K20 grain (0.0005 Gm.) of scopo- pon, with 1/1.50 to 34oo grain (0.0004 

lamine to twice these amounts, given to 0.0006 Gm.) of scopolamine is held 

either in one dose one-half to two to be without danger in strong in- 

hours before the time of operation or dividuals of middle age, though in 

in divided doses. In small-sized pa- delicate or old persons with respira- 

tients, doses somewhat less than tory disturbances the dose of pan- 

those mentioned may be given, e.g., topon should be considerably less. 

% grain (0.008 Gm.) of morphine Reichel and Keim, on the other hand, 

and ^.rjo grain (0.0004 Gm.) of specifically mention respiratory de- 

scopolamine. pression as a possibility in the use of 

The procedure is advantageous in pantopon. Reichel much prefers to 
many ways, allaying the patient's ap- substitute for the latter narcophine, a 
prehension, diminishing after-pain by meconic acid compound of morphine 
lengthening the period of narcosis, and narcotine. Keim has found thirst 
and distinctly lessening postanesthe- a troublesome symptom after panto- 
tic vomiting. The inhalation an- pon-scopolamine anesthesia, 
esthetic is taken quietly, rapidly, and Morphine-Scopolamine Preliminary 
without struggling, little or no secre- to Local and Spinal Analgesia. — 
tion in the mouth and respiratory In local and spinal types of analgesia 
tract takes place, anesthesia is main- the patient remains alert and appre- 
tained with a very small expenditure hensive, and at times has trouble, 



106 SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 

especially under local analg"esia, in any pain, or at least, if pain is ex- 
keeping- himself under control. To perienced, recollection of it after the 
overcome this difficulty and facilitate operation is completely or largely 
the surgeon's work, as well as in local 1)lotted out. 

analgesia, which is frequently incom- Morphine-Scopolamine in Obstet- 

plete, to reduce the shock to the rics. — The combination of morphine 

nervous system from tissue injury by and scopolamine was first employed 

dulling the sensibility of the sensory in obstetrics in 1903 by Steinbuchel, 

centers, morphine and scopolamine merely to reduce the pain attending 

may be employed to great advantage, labor, without producing any degree 

W. Wayne Babcock usually orders of narcosis. The procedure definitely 

administered, one hour and a quarter intended not only to reduce suffering, 

before the induction of spinal anes- but also to banish the memory of 

thesia, % grain (0.01 Gm.) of mor- pain after the completion of labor 

phine sulphate and Vioo grain (0.0006 was, however, elaborated by C. J. 

Gm.) of scopolamine hydrobromide. Gauss, of Kronig-'s clinic in Freiburg, 

Where, shortly after, the patient is who in 1907 reported 1000 cases in 

not in a condition of distinct drowsi- which this method had been success- 

ness (though still showing some re- fully applied. In the following year 

sponse when spoken to), an additional Kronig reported a series of 15O0 

dose of each remedy is given twenty cases, in which one child had died 

minutes after the first. If, as is the during delivery and three others in 

case in a few instances, the effect is the first three days after delivery, 

still insufficient, a third dose is given. Thereafter it was not until . a more 

sometimes of only one of the drugs, recent favorable report of 5000 cases 

stress being laid rather on the mor- liad been made by Gauss that wide- 

phine in young and on the scopola- spread interest in the method was 

mine in older subjects. Before major reawakened. 

operations under local anesthesia, in The price of success and relative 
which a deeper soporific effect is, in safety in the use of this procedure is 
general, of advantage, Babcock sup- held by many to be a rigid adherence 
plements the morphine-scopolamine to the somewhat complex and pains- 
administration with a narcotic enema requiring original method of Gauss, 
consisting of Hoffman's anodyne who, in the process of obtaining a 
(Spiritus setheris compositus, U.S. P.), simple state of amnesia with partial 
^ to 1 fluidounce (15 to 30 c .c.) ; insensibility to pain, — the so-called 
paraldehyde, 2 fluidrams to Yi fluid- twilight sleep (Dammerschlaf), — 
ounce (8 to 15 c.c), and water, 5 carefully adjusts the dosage to the 
fluidounces (150 c.c). At the con- individual case by means of a 
elusion of the operation 2 quarts (lit- "memory test" carried out at inter- 
ers) of normal saline solution are vals during the course of labor. In 
introduced in the bowel to accelerate primiparse, the first sedative injection 
elimination of the narcotics. By these is given when good uterine contrac- 
means the patient operated under tions are taking place every four or 
local anesthesia passes through the five minutes and persisting at least 
operation without being conscious of one-half minute. This injection con- 



SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 107 

sists of 0.01 Gm. (% grain) of mor- Gm. (Yi^o grain). This is followed 
phine hydrochloride, and 0.00045 Gm. in three-quarters of an hour by 0.0003 
(%40 grain) of scopolamine hydro- Gm. (^/2oo grain) of scopolamine 
bromide, injected separately into the alone, and in three-quarters of an 
buttock or thigh. Three-quarters of hour more by narcophine, 0.015 Gm. 
an hour later, the same dose of sco- (>^ grain), and scopolamine, 0.00015 
polamine is repeated alone. One-half Gm. (^/4oo grain). The sedative ac- 
hour after, a memory test is used, the tion is thereafter maintained by re- 
patient being asked how many injec- peating the scopolamine in 0.00015 
tions she has had, and if she remem- Gm. (i/4oo grain) doses every two 
bers some strange object, such as a hours. Repetition of the narcophine 
drinking-cup, exhibited to her at the is seldom required, though it may be 
time of the first injection. The mem- given at six-hour intervals in a pro- 
ory test is repeated thereafter, using longed labor. 

new objects each time, every half- Opinions as to the value of mor- 
hour, and if memory is still present phine or narcophine-scopolamine ad- 
one and a half hours after the second ministration in obstetrics vary from 
injection a third injection of scopo- enthusiastic advocacy of the measure 
lamine, 0.0003 Gm. {Y200 grain) only, as a routine procedure — barring cer- 
is given. Subsequent memory tests tain definite contraindications — to 
may indicate additional injections of complete condemnation. B. C. Hirst 
scopolamine, but these should be summarizes the disadvantages of the 
small, and given only at long inter- method as "prolongation of labor, 
vals. No additional morphine is ad- tendency to atony of the uterus with 
ministered after the first dose. To hemorrhage, and an increased propor- 
permit the development of a proper tion of apneic babies that could not 
"twilight sleep," absolute quiet and be revived." With minimum doses 
plugging of the patient's ears and of the two drugs these disadvantages 
covering of her eyes are of impor- disappeared, but the relief afforded 
tance. The maternal pulse, pupil re- was scarcely noticeable. He found 
flexes, and temperature, as well as the the method of value, however, chiefly 
fetal heart rate, are to be taken every for its psychic effect, in neurotic 
half-hour so quietly that the patient's primiparse in whom a long, painful 
state of sopor will not be disturbed. labor is considered probable. J. C. 
In order to increase the field of Applegate noted very satisfactory re- 
availability of the method, Siegel has suits in a small percentage of cases, 
elaborated a modified Gauss technique but accords the method only a limited 
in which the attempt to individualize field in obstetrics. Polak, on the 
the dosage is abandoned, a standard other hand, has reported a series of 
routine dosage being prescribed, and 155 cases with but three failures, no 
no memory tests used. When labor fetal mortality, and no post-partum 
is definitely established, the first in- hemorrhage. He asserts that nar- 
jection is given, consisting of narco- cotization of the child (beyond 
phine (morphine and narcotine me- oligopnea for a few minutes), if en- 
conate), 0.03 Gm. ()^ grain), and countered, is not the fault of the 
scopolamine hydrobromide, 0.00045 method, but of the dosage and man- 



108 



SCORBUTUS. 



ner of applying- it, and that the actual 
fetal mortality is lessened, rather 
than increased, by the procedure. In 
prirnipar?e of the physically unfit type, 
commonly becoming exhausted at the 
end of the first stage of labor, the 
method brings necessary rest be- 
tween contractions, obviates ex- 
haustion, and greatly reduces the 
proportion of cases requiring high or 
medium forceps application. In bor- 
der-line disproportion cases, if opera- 
tive delivery becomes necessary, this 
can be done with less shock and less 
general anesthesia. In cardiac and 
tuberculous cases, Polak uses the 
method to reduce the strain placed on 
the circulation in the first stage of 
labor. Contraindications to its use 
are emergency conditions, such as 
precipitate labor, placenta previa, ac- 
cidental hemorrhage, eclampsia, pro- 
lapse of the cord, primary inertia, and 
a dead fetus. The procedure may be 
applied, however, in the first stage 
to secure dilatation in malpositions, 
scopolamine, properly used, having 
been shown to favor dilatation of 
the cervix and reduce uterine spas- 
ticity. It does not diminish mam- 
mary secretion. 

L. T. DE M. Sajous, 

Philadelphia. 

SCORBUTUS.— Scorbutus, or scur- 
vy, is a constitutional disorder, dependent 
upon a deficiency of vegetable food, and 
characterized by a peculiar form of 
anemia, great mental and bodily prostra- 
tion, spongy gums, a tendency to the 
occurrence of mucocutaneous and sub- 
periosteal Hemorrhages, and a brawny 
induration of the muscles, especially those 
of the calves and the flexor muscles of 
the thighs. 

Scorbutus has almost totally disap- 
peared owing to the wise laws enacted 
by the various maritime countries, based 
on the discovery that deprivation of certain 



substances present in fresh fruit and vege- 
tables is the tmderlying cause. 

SYMPTOMS.— The early symptoms of 
scorbutus are a rapidly progressive ane- 
mia, the surface becoming dirty-looking, 
sallow, pallid, or earthy in appearance; a 
gradually increasing de))ility, emaciation, 
and indisposition for bodily and mental 
exertion; arthritic and muscular rheu- 
matoid pains in the limbs and back; men- 
tal apathy or depression; dyspnea upon 
slight exertion; the tongue may continue 
clean, but it becomes large, pale, flabby, 
and indented by the teeth. The appetite 
usually remains good. The bowels, as a 
rule, are constipated. 

Other manifestations now appear. Pe- 
techial spots arranged about the hair-fol- 
licles are observed, first on the lower 
extremities, later on other parts of the 
skin surface. These spots are followed 
by large subcutaneous extravasations and 
puffy swellings in various parts of the 
body, apparently due to deep-seated co- 
pious hemorrhages, as, later, the surface 
over them becomes ecchymotic. These 
swellings chiefly occupy the popliteal 
spaces, the anterior aspects of the elbows 
and of the lower part of the legs, the 
space behind the angles of the jaw, and 
the loose connective tissue in and about 
the eyelids, giving them a puffy, bruised- 
like appearance, and often accompanied by 
a sanguineous accumulation in the sub- 
conjunctival tissue covering the eyeball. 

The gums now begin to swell, especially 
at the edges, become spongy and lobu- 
lated, rising sometimes above the teeth 
and concealing them. They are deep-red 
or livid in color, bleed easily, ulcerate or 
slough, and give rise to an exceedingly 
fetid odor. The teeth often become loose 
and, in exceptional cases, drop out. A 
tendency to ulceration or sloughing be- 
comes more or less general in all parts 
of the cutaneous surface, more especially 
at the locations of the puffy swellings, be- 
ing easily induced by a slight scratch, 
pressure, or blow. 

The anemia increases. The face be- 
comes puffy and anasarca, more or less 
marked, appears in the lower extremities; 
dyspnea develops; the heart-action be- 
comes feeble and irregular, and the pulse 
small, soft, and, on exertion, much ac- 



SCORBUTUS. 



109 



celerated. The slightest exertion excites 
attacks of sudden syncope, which may be 
fatal. 

Late in the disease the appetite is apt 
to fail; the bowels become loose, the 
stools being usually very ofifensive, and, 
not infrequently, containing blood; nerv- 
ous symptoms are now manifest; visual 
disorders, including hemeralopia and nyc- 
talopia, tinnitus aurium, vertigo, insomnia, 
and late delirium may be present; menin- 
geal hemorrhage may occur. The intellect 
usually remains unaffected. 

During the progress of the disease 
thoracic complications maj^ appear, such 
as pleurisy with effusion (often bloody), 
pulmonary congestion with extravasation 
of blood into the lung-tissue, bronchial 
congestion, cough, and blood-stained sputa, 
having, not infrequently, a gangrenous 
odor. 

The urinary symptoms vary. Albumi- 
nuria is not rare. The specific gravity of 
the urine is increased, the color high, the 
solids diminished, excepting the phos- 
phates, which are usually larger in amount. 
Nephritis may occur. 

The bones in chronic cases may become 
congested, or even necrotic, and the epi- 
phyces separate from the shafts. 

The duration of scurvy may be several 
weeks or months. Death commonly re- 
sults from sudden syncope or from grad- 
ual asthenia, hastened, in some cases, by 
the occurrence of ulceration, hemorrhage, 
thoracic affections, or other complications. 

DIAGNOSIS.— The diagnosis is made 
from the history, the peculiar facies, the 
spongy and swollen gums, the gingival 
and deep-seated cutaneous hemorrhages, 
the increasing loss of strength and energy, 
the mental depression, and the rapid re- 
sponse to correct treatment. 

From purpura hemorrhagica it is dis- 
tinguished by its chief causative factor — 
a diet lacking in fresh vegetables and 
fruits — by the spongy, swollen gums, 
loosened teeth, and the brawny induration 
of the limbs. In purpura hemorrhagica, 
the ecchymotic spots are not arranged 
around a hair-follicle, and the hemor- 
rhages from the mucous membranes are 
greater in amount. 

ETIOLOGY. — Tn former times scorbu- 
tus was prevalent among sailors on pro- 



longed voyages, in armies in active service, 
and among people suffering from famine. 
According to Osier, the disease is not in- 
frequent among the Hungarian, Italian, 
■ and Bohemian miners in Pennsylvania. It 
is rarely epidemic. It is, however, en- 
demic, especially in parts of Russia (Hoff- 
man) and elsewhere, sweeping through 
prisons, barracks, almshouses, and institu- 
tions of like character. 

The chief predisposing cause is a long- 
continued dietary, lacking in certain essential 
but obscure substances found in fruits and 
fresh vegetables. Unhygienic surround- 
ings, excessive muscular exercise, humid- 
ity, cold, and other debilitating influences 
are recognized as etiological factors. Testi 
and Beri have isolated a micro-organism 
which the}' believe to be pathogenic. 

PATHOLOGY.— The pathology of scor- 
butus corresponds to the symptoms. Mi- 
croscopic examination of the blood reveals 
the presence of profound anemia; the 
blood is of low specific gravity, thin and 
dark, contains an excess of fibrin, less 
hemoglobin, and fewer red blood-cells, 
but there is no leucocytosis. The skin 
may be the seat of ecchymoses (subcu- 
taneous hemorrhages), but the most char- 
acteristic hemorrhage is that under the 
periosteum of the femora. Extravasations 
of blood, in various stages of transforma- 
tion, may also be found in the lung-sub- 
stance, beneath the pleurae, in the heart- 
muscle, in the subpericardial tissue, in the 
intestinal parietes, and beneath the peri- 
toneal membrane. Blood-stained serum 
may be found in the various serous cavi- 
ties. The internal organs ma}-, or may 
not, be congested. The brain is usually 
intact. The heart, liver, and kidneys are, 
occasionally, the seat of parenchymatous 
or fatty degeneration. 

PROGNOSIS.— If the disease has not 
progressed too far and appropriate treat- 
ment is available, the prognosis is good; 
otherwise, the outlook is grave. The in- 
ternal symptoms, especially the pulmo- 
nary, are more serious than the external 
ones. Pneumonia, hemorrhagic infarct of 
the lung, pleurisy with bloody effusion, 
acute nephritis, or dysentery, is usually 
followed by death. 

TREATMENT.— Prophylaxis demands 
an adequate supply of antiscorbutic food 



110 



SEASICKNESS (WITHERSTINE). 



for long seavoyagcs, military campaign- 
ers, and explorers in the frozen zones. 
This is facilitated by the present-day abun- 
dance of canned fruits and vegetables, 
though canning may reduce their value. 

In the treatment of the disease the two 
indications are to provide a diet of citrus 
fruits and of vegetables containing the 
necessary antiscorbutic vitamincs or salts, 
and to combat special symptoms and com- 
plications. The use of the juice of two 
or three lemons or oranges daily will be 
followed by marked improvement. 

If the digestion is feeble give orange- or 
lemon- juice combined with meat-juice or 
egg-album.in, milk and farinaceous foods. 
When the condition improves, the stronger 
animal foods and fresh antiscorbutic vege- 
tables, such as potatoes, water-cress, raw 
cabbage, onions, carrots, turnips, tomatoes 
and sauer kraut should be used freely. 

Orange peel has been found to be anti- 
scorbutic. According to A. F. Hess, boiled 
orange juice, given intravenously, acts like 
a cliarm in scurvy. 

Ulcerations in the mouth may be healed 
by using a mouth-wash of boric acid solu- 
tion. To relieve the swollen, spongy gums 
a 2 per cent, solution of tannic acid, or a 
mouth-wash containing boric acid, tincture 
of myrrh, and compound tincture of ben- 
zoin may be used. 

Twelve cases of scurvy in the Idiot 
Cottages at Kew, Victoria, all in crip- 
ples confined to bed or chair, of both 
sexes. There had been no alteration 
in the dietary of the patients for 
years. Other patients suffering from 
the same crippled conditions and with 
the same foods were unafifected. The 
scurvy cleared up in t^^e majority of 
cases shortly after the patients re- 
ceived a special dietary of raw eggs, 
lime water, lemon juice and raw milk. 
Lind (Med. Jour, of Austral., Aug. 9, 
1919). s. and W. 

SCORBUTUS, INFANTILE. 

See Infantile Scorbutus. 

SCROFULA. See various forms 
of Tuberculosis. 

SCROFULODERMA. See Tu- 
berculosis OF Skin. 



SEASICKNESS.— D E F I N I - 
TION, — Seasickness may be detined 
as an indisposition, characterized by 
giddiness, nausea, vomiting, and de- 
pression, produced by the motion of 
a vessel on the waves. Closely allied 
and somewhat similar conditions are 
elevator- and car- sickness. Regnault 
recognizes two forms of seasickness, 
the somatic (gastric) and the psy- 
chical (nervous), or that which is the 
work of the imagination or results 
from seeing others affected. 

SYNONYMS.— Seasickness is also 
known as naupathia ; nausea marina 
seu maritima; morbus maritimus 
(L.) ; mal de mer, naupathie (F.). 

SYMPTOMATOLOGY. — De 
Vries recognizes four stages : depres- 
sion, exhaustion, reaction, and con- 
valescence. In mild cases the patient 
is but slightly ill, sufifering from 
malaise and giddiness, followed by 
tinnitus, headache, yawning, and 
drowsiness, with some gastric dis- 
tress. In more severe cases, nausea, 
vomiting, vertigo, anorexia, moderate 
prostration, a greenish or grayish 
pallor, and unsteadiness of gait are 
present. In the very ill great pros- 
tration may supervene. Constipation 
or diarrhea may be present. All the 
secretions are diininished (including 
the menses) except the saliva, the 
flow of which may be excessive. 
Diplopia, pain in the eyes, scotoma, 
staggering gait, muscular relaxation, 
backache, neuralgic pains, alternating 
warm flashes and chilliness, weak and 
rapid pulse, clamni}^ skin, profuse 
diaphoresis, insomnia, fear, and a 
feeling of general depression are com- 
monly noticed. There are more often 
mental depression, nervous exhaus- 
tion, unpleasant delusions of the 
senses of taste and smell, and. more 



SEASICKNESS (WITHERSTINE). HI 

rarely, deficient intellectual control, center, which, with the nuclei of the 

One of the first symptoms in certain- eighth nerve, also lies in the fourth 

cases is an abnormal appetite, which ventricle. There follows obstinate 

appears as soon as rough water is vomiting, often associated with great 

encountered. prostration. The endolymph follows 

COMPLICATIONS AND SE- the motion of the head in those 
QUEL.ffi. — Cerebral hemorrhage or canals whose plane corresponds most 
the rupture of a previously existing nearly to the direction of that mo- 
gastric ulcer is not infrequent, tion, and when the motion is sud- 
Brewer, U. S. A. Medical Corps, men- denly reversed by the oscillation of 
tions a case in which the vomiting the ship, or changed in direction by 
was so severe that a vessel in the a new wave striking her on another 
stomach was ruptured and consider- point, the endolymph continues in its 
able blood lost ; the child was ill for original direction until stopped by 
several days after landing. He re- friction. This causes undue pressure 
ports another case in which a phy- in one or more of the ampullae, by 
sician who, in addition to the usual which wrong impressions are con- 
symptoms, sufifered from a severe veyed to the sensorium, and in- 
diarrhea whenever the sea was rough, co-ordination and giddiness result. 

Among the most frequent sequelae Moreover, the otoliths are washed up 
are vertigo, anorexia, constipation, against the nerve filaments at the 
nervousness, and invalidism, these front of the semicircular canals and 
symptoms persisting after the patient produce an excessive irritation, which 
has left the ship. Bushby, of Liver- is expressed in vertigo and vomiting, 
pool, reports two cases of severe, James L. Minor, of Memphis, calls 
prolonged prostration following sea- attention to the freedom of deaf- 
sickness and associated with aceto- mutes from seasickness as a proof of 
nuria. Beard mentions the case of a its aural origin, adding that nausea 
man, sick an entire year at sea, who and dizziness are results of irritated, 
could not enter any place where the but not destroyed (as in deaf-mutes), 
air was foul without feeling the semicircular contents, 
symptoms of seasickness. . The theory that "anemia of the 

ETIOLOGY. — The etiology of sea- brain" causes seasickness was ad- 
sickness is far from being absolutely vanced by C. Binz, of Bonn. He 
settled. Many theories have been claims that (1) the motion of the ship 
advanced, of which the "endolymph causes constriction of the arteries of 
theory" is the most generally ac- the brain and consequent anemia of 
cepted one. According to William that organ ; (2) this acute, local ane- 
Edgar Darnall the motion of the mia gives rise, as at other times, to 
waves with the rhythmic intervals be- rapidly recurring nausea and vomit- 
comes transmitted to the endolymph ing; (3) the retching and vomiting 
of the semicircular canals. This con- then increases the volume of blood in 
tinual flowing in a given plane over- the brain and, in that way, relieves 
irritates the fine hair-like terminals of the cerebral anemia and removes the 
the vestibular nerve in the labyrinth, sense of nausea ; (4) the stomach 
and reflexes are sent to the vomiting plays a passive role, being influenced 



112 SEASICKNESS (WITHERSTINE). 

by the central nervous system to act pressed in nausea and alteration in 

whether it is empty or full; (5) every- the respiratory movements, 

thing that facilitates the flow of blood Dubois ascribes a causal relation to 

to the brain, and increases the same, incomplete ventilation of the lungs, 

acts as a prophylactic, mitigates, or with an increase in residual air, 

cures the seasickness. and imperfect respiratory changes. 

Germane to this is the "theory of The secondary phenomena, headache, 

Pflanz," that the constant change in vomiting, and chills are referred, 

blood-pressure and in the fullness of etiologically, to the spasmodic and 

the blood-vessels produces an irrita- forcible contractions of the diaphragm 

tion in the brain which, when it with a consequent displacement of 

passes the stage at which it can the viscera. 

be borne, evokes the characteristic Kenneth F. Lund, of Dublin, after 

symptoms of this condition. reviewing the various theories as to 

Metcalf Sharpe suggests that the the causation of seasickness concludes 
condition is the result of a reflex ac- that (1) the vomiting is not due to 
tion of the stomach due to a central the unusual impression of vision, for 
stimulus ; the reflex action is trans- it may occur on land, when the eyes 
mitted to the solar plexus by the are closed, and even to the blind ; (2) 
vagi ; the stimulus probably originates it is not due to smell, as any unpleas- 
in disorders of visual accommodation, ant odor may cause vomiting, and 
for by paralyzing the accommoda- may occur on land, and to any, in- 
tion of one eye, by means of a myd- eluding deaf-mutes, who have sensi- 
riatic, he found that the symptoms tive nasal organs ; (3) it is not due to 
were greatly lessened. Hewitt, of momentary displacement of viscera, 
London, believes that interference for it occurs in swinging or in de- 
with the visual center predisposes to scending upon an elevator. The sen- 
seasickness, sation is present whether the eyes are 

According to W. Janowski seasick- open or closed, but it does not occur 

ness is an expression of a mild form in deaf-mutes ; (4) there is some 

of oft-repeated cerebral concussion. mechanism in the auditory organ, 

The surprise of the mental faculty perhaps the semicircular system, 

underlying consciousness, analogous which is directly affected by the oscil- 

to strong emotional disturbance, as lations of a vessel at sea, which acts 

fright, joy, etc., is given by Losee as as a stimulus to the vomiting center, 

the causative agent in this disorder. Finally, the nervous element and 

Dastre and Pampoukis believe that power of the imagination, as causa- 

there is a combination of etiological tive factors, should not be disre- 

factors, of the central nervous sys- garded, especially in those of a highly 

tem, the pneumogastric, the splanch- sensitive and nervous temperament, 

nic, and the phrenic nerves, and that Age has some etiological impor- 

the displacement of the abdominal tance. Children and the very aged 

viscera and their slipping motion on rarely suffer from it, although chil- 

each other probably cause stimulation dren may, purely out of sympathy, 

of the Paccinian bodies of the mes- Females are more frequently affected 

entery, the effect of which is ex- than males. Only from Yz to 5 per 



SEASICKNESS (WITHERSTINE). 



113 



cent, of all persons escape. Gihon should occur, raise the head or sit up 

estimates that 5 per cent, are immune, awhile. Keep always in the cool air 

that 25 per cent, are but little sick, on deck with pleasant companions, 

that 60 per cent, are a great deal sick, save for meals and bed, moving about 

and that 10 per cent, are distressingly as little as possible, until accustomed 

ill. to the ship's motion. Avoid oleagin- 

PROGNOSIS. — Seasickness is sel- ous smellsi and the company of those 

dom, in itself, a menace to the life of who are seasick, as suggestion is a 

a patient. powerful excitant to seasickness. 

PROPHYLAXIS.— Choose a fa- Avoid cold food. Vichy and Ap- 

vorable season (spring or summer), pollinaris waters may be freely in- 



if possible, for the voyage. Avoid 
sailing on the long, narrow ocean- 
greyhounds which roll with each 



dulged in throughout the voyage. 
Small and frequent (at least seven) 
meals are best. M. Charteris. of 



swell and pound the ship into con- Glasgow, insists that the diet for the 

stant motion with their powerful first two days should be dry and 

engines, but select, rather, one of spare, no full meals being taken, and 

the broad-beamed, slow-going boats soups and pastries always avoided, 

which are now so well fitted for the If there is any tendency to nausea, 

comfort of the passengers, as well as exertion should be avoided, as much 

carrying freight. Select stateroom as possible ; the sufiferer should be on 

and deck quarters in the middle of his back, with a small pillow under 

the ship, near its transverse axis, the the head, or none. 

point where the rolling of the vessel As to drugs suggestions are numer- 

is least felt. A thorough hepatic ous. No drug or combination of 

purge should be taken the night be- drugs is infallible. A. D. Rockwell, 

fore embarking, and a saline on the of New York, strongly advises bro- 

following morning. Go on board the mization — 100 grains (6,6 Gm.) in 

vessel rested in body and with a tran- divided doses daily for three days 

quil mind, after a light meal on shore, before sailing, and for three or four 

with which a little wine was taken, days after sailing. Veronal (sodium), 

but scarcely any other fluids. a favorite with many, is best given 

The clothing should be of light, in a suppository cont'aining 7^ grains 

pure, woolen material; easy, warm, (0.5 Gm.), although 5-grain (0.3 Gm.) 

comfortable, broad-soled shoes should doses may be given in tablet form, by 

be worn. A good flannel roller band- mouth. Chloretone, another favorite 

age, 12 feet long and 6 inches wide, remedy, may be given in 5-grain 

enveloping firmly the whole abdomen (0.3 Gm.) capsules, tablets, or pow- 

will frequently afford great comfort ders, every 3 hours for 3 doses, so 

and prevent undue movement of the arranged that the last shall be taken 

viscera. on embarking. For short voyages 

A steamer-chair and rug should be this is usually effective ; for longer 

provided. Recline on deck in a shel- ones the drug should be continued 

tered place, amidship, on the leeward longer. Validol, higlily recommended 

side, comfortably covered and with by many, is best given in liquid form 

eyes closed. If cerebral congestion on a lump of sugar, the first dose be- 

8—8 



114 



SEASICKNESS (WITIIERSTINE). 



\n^ 30 drops, the second 25 drops, and 
tlic third 15 drops, taken an hour 
apart, the first dose two or three 
lujurs before sailinj^. It may also be 
lakeii in doses of 10 to 15 minims 
(0.6 to 1 (ini.), repeated half-hourly, 
if rc(|uircd, plain (neat), in a weak, 
alrolioHc solution, or in li(|uid form. 
A j)rophylactir injection of '/,„) ,i;rain 
(0.0006 dm.) of atropine sulphate, 
combined with Hi, ^rain (0.(X)12 Gm.) 
of strychnine sulphate, as sut^^ested 
by (lirard and olliers, will d(j much 
to inhibit the onset. Avoid the use 
of morphine, cocaine, and parej^'oric, 
which at times are tlionL,ditlessly 
recommended. 

TREATMENT.— Whenever the 
slis^lUest sensation of illness is felt He 
down at once and close the eyes. 
Usually one pillow suffices, and if 
very ill, none should be used. Two 
teaspoon fuls of peptone in sherry 
wine, poured over cracked ice, may 
be ,i;iven every half-hour, as su£^- 
.q'ested by Sinclair Tousey. If the 
patient is very ill and cannot eat or 
retain food, 11. I'artsch recommends 
an egg-nog, prei)ared by mixing the 
yolks of two raw eggs with an equal 
bulk of good brandy or sherry well- 
beaten together, and given in tea- 
si)oonful doses at ten-minute inter- 
vals. Patients with severe retching 
will be made comfortable by lying 
down, without a ])illow, the eyes 
closed; a pint of beer, ale, or porter 
(brown stout) is then taken in six or 
eight portions at fivc-minute inter- 
vals. Champagne frappe or ginger 
ale with 20 per cent, of brandy or 
whisky is highly praised by many. 
When champagne is used it is advis- 
able to allow it to stand until effer- 
vescence ceases, that eructations be 
avoided. Beef-tea or meat broths, in 



tablespoonful doses, may be retained. 
Food should always be taken at 
least ten minutes before arising in the 
morning, and when the patient is ill 
all food slunild be taken without rais- 
ing the head. The best time to take 
any beverage or fo(jd is just after a 
l)aroxysm of retching. Should it be 
taken before and vomited, then take 
another dose immediately afterward, 
and that will stay down (11. I'artsch). 
The sicker the patient, the oftener he 
must eat, and the less at a time. The 
bowels should be kept open by laxa- 
tives or warm-water enemas. 

The drugs most in favor in this 
condition aie veronal, chloretone, vali- 
dol (the administrati(jn of which has 
been already described under ])rophy- 
laxis), atropine, atropine and strych- 
nine ccjinbined, nitroglycerin (s])iritus 
gly eery lis nitratisj, and amyl nitrite. 
The bromides have largely fallen into 
disuse, except ior rclieviiig the head- 
ache, because they tend to disorder 
the digestion. 

Atro])ine is given, to increase the 
cerebral blood-su[)ply and to relieve 
atony of the vagus, hypodermically, 
in doses of /■'j^o to %(» grain (0.0005 
to 0.001 Gm.), to be repeated in three 
or fom- hours, if necessary. Atropine 
sulphate, ^^o grain (0.0005 Gm.) 
may be advantageously combined 
with i/;„ grain (0.001 Gm.) of 
strychnine sulphate. 

Nitroglycerin and amyl nitrite have 
been used in full doses. 

Rosenthal has shown that every 
reflex action can be i)revented by 
•apnea. This principle is applied for 
the suppression of the vomiting 
(which is due to a reflex stimulatitm 
of the center in the fourth ventricle) 
by directing the patient to take a 
series of deep inspirations. The sue- 



SENEGA. 



115 



cessful experiments of Rosenthal have 
been repeated by R. Heinz and M. 
Kaufmann. 

Bier's method of hyperemia has 
been successfully used by Rosen and 
by Schlag"er to reheve the nausea of 
seasickness. The hyperemia was in- 
duced by fixing an elastic band 
around the neck. This had no influ- 
ence on the tendency to vomit when 
the stomach was full, but when the 
stomach was empty the tendency to 
vomit ceased. The band was always 
removed at night. 

Based on his theory (see Etiology) 
M. Dubois advised inhalations of 
oxygen under pressure, through the 
mouth. These were followed by 
rapid improvement. The number of 
inhalations was not very large, the 
amount of gas inhaled being usually 
from 30 to 40 liters. Dutremblay and 
Perdriolot attest the efficiency of this 
treatment. 

Wolf applies hot-water compresses 
to the forehead, as hot as can be 
borne, and rapidly alternated. They 
are at first badly tolerated, but after 
a little time they produce a thorough 
sense of relief. Adrenalin given in- 
ternally has also been praised. 

Ahhough the number of cases in 
which the writer used benzyl benzoate 
in seasickness is small, about 20 in 
all, the results in every case were so 
satisfactory that he feels justified in 
recommending it. In his cases 10 
drops were used. As the sea voyage 
was short in all cases, he was not 
able to determine how long the effect 
of the drug would last. Glenn (Calif. 
State Jour, of Med., Nov., 1920). 
C'. Sumner Withekstine, 

Philadelphia. 

SENEGA. — Senega (senega, snake- 
root) is the dried root of Polygala senega 
(fam., Polygalacere), a perennial herb of 
eastern and central North America, as far 



south as North Carolina. The constitu- 
ents of senega are a saponin-like mixture 
made up of polygallic acid (about three- 
fourths of the whole) and senegin, a 
jmall amount of methyl salicylate, resin, 
fat, sugar, etc. It contains neither tannin 
nor starch. 

PREPARATIONS AND DOSES.— 
Senega, U. S. P. (the dried root). Dose, 
10 to 20 grains (0.60 to 1.20 Gm.). 

Fluidcxtractiiin scnegice, U. S. P. (fluid- 
extract of senega). Dose, 10 to 20 min- 
ims (0.60 to 1.20 c.c). 

Syrupns senega;, U. S. P. (syrup of sen- 
ega — 20 per cent, of the fluidextract). 
Dose, 1 to 2 drams (4 to 8 c.c). 

Syrupus scillce compositiis, U. S. P. (com- 
pound syrup of squill, hive syrup, croup 
syrup, an ofificial substitute for Coxe's 
hive syrup, containing 8 per cent, fluid- 
extracts senega and squill, and 0.2 per 
cent, tartar emetic). Dose, 10 to 30 
minims (0.60 to 2.0 Gm.). 

Alistura pcctoralis, Stokes, N. F. (Stokes's 
expectorant). Dose, 1 dram (4 c.c), con- 
taining 2 grains (0.12 Gm.) each of sen- 
ega and squill, 1 grain (0.06 Gm.) of am- 
monium carbonate, and 10 minims (0.6 
c.c. of paregoric in syrup of Tolu. This 
is a favorite mixture, though not official. 

PHYSIOLOGICAL ACTION.— Senega 
is an expectorant, alterative, diaphoretic, 
and diuretic The powdered root is irri- 
tating to the air-passages and its inhala- 
tion causes sneezing. When the root is 
chewed a burning sensation follows. 
When swallowed in large doses it causes 
salivation and gastrointestinal and renal 
irritation. It is an irritant to the skin. 
Used as an expectorant, it does not 
liquefy the secretions, but merely facili- 
tates their expulsion; senega, therefore, is 
of little use when the expectoration is 
tough and scanty. It is usually combined 
with other expectorants and diuretics. 
Senega is excreted by the bronchial mu- 
cous membrane, the skin, and the kidneys, 
exerting a stimulating action upon these 
organs. 

THERAPEUTIC USES. — Senega is 
cliicfly used in subacute and chronic 
bronchitis, in the chronic bronchitis of 
the aged, ijften associated with emphy- 
sema, and by some in croup. In bronchial 
asthma with emphysema, the drug is 



116 



SENNA. 



SERPENTARIA. 



beneficial. Whooping-cough is sometimes 
relieved by senega. On account of its 
diuretic action senega has given relief in 
the dropsy of renal disease and in palpi- 
tation unasMiciated with cardiac disease. 
In amenorrhea it has given good results. 
The use of senega in heart disease is not 
advised on account of the depressing ac- 
tion of its active principle. In doses of 2 
grains (0.13 Gm.) senega has been given 
to check uterine hemorrhage. Senega has 
been given in chronic rheumatism for its 
diaphoretic and diuretic effects. 

SENNA.— Senna is the leaflets of 
Cassia acutifolia (Alexandria senna) and 
Cassia angustifolia (India senna), family 
Leguminoseae, freed from stalks, discol- 
olored leaves and other admixtures. 
The principal constituents, according to 
Tschirch, are one or more glucosides, 
yielding emodin, an extractive substance 
(cathartic acid) and a large amount of 
gum resin, the non-fermentable sugar 
cathartomannite, a bitter (sennapicrin), 
oxalic, malic and tartaric acids combined 
with calcium, and a trace of volatile oil. 
Senna has a faint, disagreeable odor and a 
bitter, nauseous taste. 

PREPARATIONS AND DOSES.— 
Senna, U. S. P. (senna leaves). Dose, 1 
to 2^ drams (4 to 10 Gm.). 

Fhiidextractum senivcB, U. S. P. (fluidex- 
tract of senna). Dose, J^ to 1 dram (2 to 
4 c.c). 

Infusum sennce compositum, U. S. P. 
(black draught, containing 6 per cent, 
senna, 12 per cent, manna and magnesium 
sulphate, and 2 per cent, bruised fennel 
seeds). Dose, 2 to 4 ounces (60 to 
120 c.c). 

Syrupus senmu, U. S. P. (syrup of senna, 
containing 25 per cent, of fluidextract). 
Dose, 1 to 2 drams (4 to 8 c.c). 

Piilvis glycyrrhiscE compositus, U. S. P. 
(compound licorice pow^der, containing 18 
per cent, senna, combined with washed 
sulphur, licorice powder, fennel oil, and 
sugar). Dose, ^^ to 2 drams (2 to 8 Gm.). 
Efficient but unofficial preparations are: 
Confectio sennse, N. F. (confection of 
senna, containing the pulps of cassia 
fistula, prune, tamarind, and fig, with 10 
per cent, senna flavored with coriander 
oil). Dose, 1 dram (4 Gm.). 



Syrupus sennrc aromaticus, N. F, Dose, 
2 drams (8 c.c), representing IS grains 
(1 Gm.) deodorized senna, 6 grains (0.4 
Gm.) jalap, and 2 grains (0.13 Gm.) rhu- 
barb, with aromatics. 

Syrupus sennie compositus, N. F. Dose, 
2 drams (8 c.c), representing 16 grains 
(1.04 Gm.) senna and 4 grains (0.26 Gm.) 
each of rhubarb and frangula. 

PHYSIOLOGICAL ACTION.— Senna 
is an active, but not acrid, cathartic, act- 
ing in about four hours and producing 
copious, yellow stools, with some griping 
which may be avoided by combining it 
with aromatics. It is a feeble hepatic 
stimulant, rendering the bile more watery. 
The menstrual flow may be excited by it, 
and if given to a nursing woman her milk 
thereby becomes a purgative. Injected 
into the veins it causes vomiting and 
purging, and in overdose a drastic cathar- 
tic, but it never produces poisonous ef- 
fects. The urine acquires a red color 
from senna medication, if it is acid, but 
in an alkaline urine the normal yellow 
color is more pronounced. 

THERAPEUTIC USES.— This drug is 
a safe, efficient, and, when combined with 
other drugs, a pleasant cathartic for con- 
stipation. For children and pregnant 
women the confection and the compound 
licorice powder are advised. It is contra- 
indicated in threatened abortion, hemor- 
rhoids, and where the intestines are 
inflamed. 

SEPSIS, SEPTIC FEVER, SEP- 
TIC INFECTION, SEPTIC POI- 
SONING, SEPTICEMIA. See 

Wounds, Septic. 

SEPTUM, DISEASES OF. See 

Nose and Nasopharynx, Diseases of. 

SERA. See Diseases in whicli 
these are used ; also Hematology. 

SERPENTARIA. - Serpentaria is 
the dried rhizome and roots of Aristolochia 
serpentaria, Virginia; or of Aristolochia 
reticulata, Texas (fam., Aristolochiaceae). 
The Virginian species may be found 
throughout the eastern United States, 
and is chiefly collected in the mountain- 
ous districts south of Pennsylvania and 



SHOCK. 



117 



the Ohio River. Serpentaria, an aromatic 
bitter, contains a volatile oil (0.5 to 1 per 
cent.), a bitter principle, tannin, starch, 
sugar, gum, and resin. It has a warm, 
pleasant taste. 

PREPARATIONS AND DOSES.— 
Serpentaria, U. S. P. (the crude drug). 
Dose, 10 to 30 grains (0.60 to 2 Gm.). 

Fluidextractum serpentari?e, N. F. (fluid- 
extract of serpentaria). Dose, 10 to 30 
minims (0.60 to 2 c.c.)-. 

Tinctura serpentarire, N. F. (tincture of 
serpentaria, 20 per cent.). Dose, J^ to 2 
drams (2 to 8 c.c). 

PHYSIOLOGICAL ACTION. — Ser- 
pentaria has a stimulating effect upon 
gastric secretion and is added to other 
drugs to increase their absorption and ac- 
tivity. It has a mild diuretic and diapho- 
retic action. In larger doses it pro- 
duces a sense of fullness in the head, 
nausea, vomiting and intestinal griping 
with frequent evacuations of semisolid 
stools. Hemorrhoids are irritated and 
menstruation stimulated. It is also an 
expectorant. 

THERAPEUTIC USES.— Serpentaria 
is a good general tonic. It is seldom used 
alone. In atonic dyspepsia it is useful, 
combined with the compound tincture of 
cinchona. In combination with the aro- 
matic spirit of ammonia it is beneficial 
in pneumonia of a low type, in bronchial 
catarrh, and in capillary bronchitis. It is 
valued as a restorative in typhus and ty- 
phoid fevers. It has been used with bene- 
fit in chronic rheumatism, combined with 
other remedies. Serpentaria has given 
good results in amenorrhea dependent 
upon anemia or chlorosis. 

SHINGLES. See Herpes Zoster. 

SHOCK. — DEFINITION. — A gen- 
eral depression of the vital functions due 
to traumatism, a profound emotion, fear, 
etc., characterized by chemicophysical dis- 
turbances in the nervous system, in which 
deficient adrenal activity and vasomotor 
paresis are prominent features. 

SYMPTOMS.— Shock may present it- 
self in forms varying in intensity froin 
slight depression to profound collapse ap- 
proximating death. In severe shock the 
temperature is subnormal, the surface is 
pale or livid and cool or cold, the skin 



being clammy and perspiring freely; the 
eyes are staring or half-closed; the res- 
piration is shallow and irregular, and 
often gasping; the pulse weak, rapid and 
compressible or imperceptible. A notable 
fall of the ])lood-pressure is usual. These 
symptoms in severe cases are accom- 
panied by loss of consciousness; in the 
less severe cases, consciousness is main- 
tained as a rule, but psychic activity ap- 
pears to be inhibited, the answers to 
questions being monosyllabic and often 
unreliable; even in mild shock mentality 
may l)e temporarily dull and apathetic. 
Weakness of the muscles is a striking 
feature, those of the surface being flabby 
and impotent; the sphincters also fail to 
functionate from this cause, and involun- 
tary evacuations may result. The pupils 
are dilated, as a rule, and react but slowly 
to light. Nausea and vomiting may oc- 
cur, but this is rather a favorable sign, 
since it is often the precursor of a reac- 
tion. Conversely, hiccough and gastric 
regurgitation are unfavorable signs. Anu- 
ria is frequently noted. 

In lethal cases, the mental torpor grad- 
ually deepens, syncope comes on, and 
death follows. This course depicts that 
observed in great injury involving con- 
siderable loss of blood, complicated prob- 
ably with abdominal or cerebral lesions. 
Neurotic individuals and drunkards are 
also exposed to this rapidly fatal form. 

In some cases the picture is quite dif- 
ferent. Maniacal furor seems suddenly to 
develop, and the patient throws himself 
or his liml)s in every direction, rolls his 
eyes, strikes right and left, and cries 
out at the top of his voice. Usually ex- 
haustion soon comes on through recur- 
rence, probalily, of hemorrhage on ac- 
count of the violent exertion. 

In cases that proceed favorably, the 
change for the better is termed the "re- 
action." All the abnormal symptoms dis- 
appear gradually, the return of the mus- 
cular tone being manifested by turning, 
shifting position, etc., while the cardiac 
symptoms lessen in intensity as the facial 
color returns. Some cases at this stage 
go through the maniacal type of shock 
through unduly rapid resumption of cere- 
bral blood-pressure. In some cases it is 
a sign of septic infection. The tempera- 



118 



SHOCK. 



ture in a favorable case remains near the 
normal, though it may exceed this to a 
marked degree in children without indi- 
cating that a complication has occurred. 
This reaction fever sometimes lasts a 
couple of days, then gradually disappears. 

As regards the differential diagnosis of 
shock, internal Jiciiiorrhage is the main 
source of confusion, since a serious trau- 
matism capable of causing deep shock is 
capable of causing also some organic in- 
jury in some part, local or remote, of the 
vascular system. This question assumes 
especial import after an operation owing 
to the possibility of concealed hemorrhage. 
In the latter case, however, restlessness, 
tossing, frequently repeated yawning, in- 
tense thirst, nausea, impairment of vision 
due to retinal ischemia, and repeated at- 
tacks of syncope are apt to occur. Re- 
peated examinations of the blood will 
serve to place the differential diagnosis 
on a surer footing, since hemorrhage pro- 
duces a gradual diminution of the hemo- 
globin percentage, while uncomplicated 
shock does not cause such a change. The 
cell count, both as to erythrocytes and 
leucocytes, may, however, indicate a 
marked decrease, but this is probably due 
to recession of the blood-mass into the 
splanchnic area, with resulting ischemia 
of the superficial vessels. It is, therefore, 
an unreliable sign. An abdominal hemor- 
rhage may give the physical signs of an 
increasing accumulation of fluid. While 
the onset of uncomplicated shock is as 
a rule sudden, the exhaustion due to hem- 
orrhage is gradual, and finally attended 
with severe asphyxic phenomena, which 
are relatively slight in shock. 

Delayed shock may come on some 
hours after an injury or a violent com- 
motion or emotion, such as is witnessed 
in street-car or railroad accidents. Anes- 
thetics, especially chloroform and ether, 
inay also be followed by shock, not only 
in the course of buti after their use. 

Shell Shock. — The European war has 
shown that shells, mines, and other 
agents of destruction in which high ex- 
plosives are employed may, irrespective 
of or without direct physical injury, give 
rise to nervous and psychic phenomena 
which have been variously attributed to 
"shock," "physical trauma," "concussion 



cerebri," etc. In the milder cases, con- 
sciousness is not lost, but there may be, 
for a time, severe pain in the head and 
spine, incoherent speech, trembling, heavi- 
ness of the extremities and temporary 
anuria. When micturition is re-estab- 
lished, the urine may be found to contain 
albumin. Uneventful recovery is usual. 

In the more severe cases, unconscious- 
ness, lasting an hour or more, is fol- 
lowed by a severe "bursting" headache 
with some deafness, tinnitus and vertigo, 
sweating, and tremor, or rhythmic spas- 
modic movements. Incoherence of speech, 
mutism, amnesia and various disorders 
may appear. Catalepsy, followed by con- 
vulsions, has also been witnessed. The 
reflexes are increasingly active, and se- 
vere pain with hyperalgesia in various 
parts of the body, including the appen- 
dical region, may be complained of. The 
cases usually recover in from one to three 
weeks. Epilepsy has also appeared in in- 
dividuals in whom a history of this dis- 
ease did not exist. 

Case of a young man buried in a 
trench by the explosion of a shell, 
who was unconscious when rescued. 
Consciousness was regained in a few 
hours, but he was totally amnesic 
so far as his whole life was con- 
cerned prior to and including the 
time of the accident. No efforts to 
recall his past life were successful, 
but the practice of hypnotism brought 
out a startling result. While under 
hypnotic influence he lost his new 
personality completely and returned 
to his original one with equal com- 
pleteness. During this state he was 
able to recognize his father, remem- 
bered all of his past life to the mi- 
nutest detail, and could even give an 
accurate account of the accident 
which caused his mental disturbance. 
Upon recovery from hypnosis each 
time he would relapse into his new 
personality and have no memory of 
his former one. During the studies 
made of him in each of his two per- 
sonalities, it was observed that his 
voice and his handwriting were dif- 
ferent in the two states. In one re- 
spect his original personality was 
retained to a certain extent, namely, 



SHOCK. 



119 



his ability to play a certain musical 
instrument. Anthony Feiling (Lan- 
cet, July 10, 1915). 

Serious disturbances are produced 
by wounds of remote localities, and 
are not necessarily psychogenic. The 
shock of the wound may cause pro- 
longed unconsciousness froin which 
patient emerges speechless or voice- 
less. Physical shock must be in- 
voked to explain such cases. A re- 
flex cause could be excluded. The 
disturbances in question comprised 
aphasia, phonasthenia, dysarthria in- 
cluding the spastic form, and kine- 
toses of all kinds, very often ac- 
companied with exhaustive states. 
Treatment was, for the most part, 
imperfectly successful with occa- 
sional good results. One soldier 
upon recovering from shock after 
protracted unconsciousness showed 
total aphasia. As this passed off 
dysarthria and dysphasia were left 
and persisted for eight months. After 
this bradylalia was the only symp- 
tom in evidence. Thirteen months 
expired before he could resume his 
duties as officer. Gutzmann (Berl. 
klin. Woch., Feb. 14, 1916). 

This fortunate issue is not, however, 
the invariable one. In some individuals, 
after weeks or months, the patients, 
though apparently recovered, show signs 
of a changed disposition, manifested espe- 
cially in abnormal irrital)ility, anxiety, 
apprehensiveness, or a condition of high 
emotional state. These may be attended 
with hallucinations, horrifying dreams, de- 
lusions, etc. They lose interest in them- 
selves and in others, become unsocial and 
morose. The repeated revival of memo- 
ries of horrible events in the trenches, the 
death of comrades, shell bursts, blowing 
up of their trench, etc., serve to sustain 
the psychic disturbance. The majority of 
these cases recover, however, but only 
under well-directed psychotherapy, in 
which sympathy is freely dispensed. 
Wounds tend to aggravate the trouble, 
and even to produce it. 

The direct effects of the contusion 
from the air are of extreme variety, 
as also the various conditions that 



may be observed afterward. Sudden 
death from the shock alone is not 
rare; immediate unconsciousness is 
common. It may last for hours or 
weeks and be followed by total loss 
of memory for the period since the 
explosion. The effects of the injury 
are, in reality, nothing but traumatic 
hysteria. When the shell explodes 
near a sleeping person, it does not 
induce the nervous and mental dis- 
turbances otherwise observed. This 
throws light on the importance of 
the fright as a factor in the shock. 
The emotional-neurotic factors are 
supplemented by the traits for which 
physical exhaustion is responsible. 
An exhausted nervous system feels 
the effect of the explosion more than 
when fresh or well rested. R. Gaupp 
(Beitrage z. klin. Chir., Apr., 1915). 

From the 156 cases studied, a large 
majority of so-called shell-shock 
cases admitted into the hospital with 
functional neurosis in some form 
occurred in individuals with a nerv- 
ous temperament, or with an ac- 
quired or inherited neuropathy. In 
a certain numl)er of cases the cumu- 
lative effect of active service had 
produced a neurasthenic or hysteric 
condition in a potentially sound in- 
dividual. Among the large number 
of officers the writer has seen sent 
back on account of neurasthenia, 
none have exhibited symptoms of 
functional paralysis or mutism. Cases 
which were supposed to have de- 
veloped epilepsy as a result of shell 
shock were, usually, individuals who 
were either epileptics or potential 
epileptics prior to the shock. F. W. 
Mott (Lancet, Feb. 26, 1916). 

ETIOLOGY AND PATHOLOGY.— 

Although the term "shock" is applied to 
a definite clinical syndrome as a rule, it 
is often made to cover, pathogenetically, 
very different conditions: hemorrhage, 
asphyxia, reflex inhibition, etc. Each of 
these, however, has its own pathology: 
cerebral ischemia in hemorrhage; deficient 
cellular oxidation in asphyxia; vasomotor 
paresis in reflex inhibition, etc. True 
shock, however, has a patliology of its 



120 



SHOCK. 



own, changes having been shown to occur 
in the nerve-cell in keeping with the older 
teachings based on the histological 
methods of Golgi, Marchi and Nissl in 
"shocked" animals. The alterations found 
by the Golgi method consist in a de- 
formity of the cell-body advancing to the 
grade of actual atrophy, node-like swell- 
ings on the dendrites, and fragmentation 
of the same. By the Marchi methods 
there is noted degeneration of various 
spinal tracts and columns. As observed 
by the methods of Nissl, the cytological 
alterations are various, but pronounced. 
Chromatolysis is present in a large number 
of cells. Changes in the nucleus, — disloca- 
tion or vcsiculation, — are also noticeable. 

As a result of the central disorder, the 
vasomotor system becomes more or less 
incompetent, and reduction of the blood- 
pressure follows; the peripheral and cere- 
bral vessels are depleted, while the larger 
trunks within the abdominal cavity are 
engorged. This may explain the greater 
danger of a fatal issue when much blood 
has been lost, the medullary and spinal 
changes being thus accentuated. 

That the adrenals become inadequate 
from the same morbid action on their 
governing center — the sympathetic center 
according to Sajous — seems probable, thus 
furnishing another causal factor for the 
low blood-pressure noted. According to 
Crile the adrenal adynamia resulting from 
shock is a prominent factor of this con- 
dition. 

The labors of Elliott and Cannon, 
Seeley and Lyon have shown that 
marked epinephrin exhaustion occurs. 
From the fact that the adrenal ordi- 
narily contains enormous loads to 
tide the individual through emergen- 
cies it would seem that the storage 
and discharge factors are paramount 
over the secretory roles. Further 
than this, the amounts of epinephrin 
needed to maintain vasoconstriction 
that exists in shock are evidence of 
the continued output of that secre- 
tion as long as an available supply 
exists. The adrenal cortex in shock 
seems unaffected. J. F. Corbett (St. 
Paul Med. Jour., xvii, 655, 1915). 

Increased quantities of epinephrin 
are thrown into the blood during con- 



ditions of low blood-pressure and 
shock. The apparent outpouring of 
epinephrin is not merely a hasty dis- 
charge and depletion of the supra- 
renals; since the quantity of epi- 
nephric material in the blood actually 
increases with the prolongation of 
low blood-pressure and shock, there 
must be an active secretion from the 
glands. The suprarenals seem to 
function as a line of secondary de- 
fence against a falling blood-pres- 
sure. The presence of epinephrin in 
increasing amounts as shock pro- 
gresses points to an attempt on the 
part of the circulation to redistribute 
the blood, bring about peripheral con- 
striction of the arteries wherever pos- 
sible, and thus maintain normal pres- 
sure. Bedford and Jackson (Proc. 
Soc. of Exper. Biol, and Med., 13, 85, 
1916). 

The writer defines shock as a grad- 
ual progressive fall of blood-pressure 
due to a paresis or paralysis of the 
musculature of the arterioles. The 
only way in which he has been able 
experimentally to produce anything 
like shock is removal of the adrenals. 
Adrenalin produces a good effect in 
shock not only because it raises the 
blood-pressure, but because it sup- 
plies a something which is essential 
and in these cases apparently lacking. 
The treatment of surgical shock con- 
sists in continued administration of 
adrenalin plus efforts to remove the 
causative factor. J. E. Sweet (Amer. 
Jour. Med. Sci., May, 1918). 

Owing to these organic disturbances, 
the contractile power of the vessels is lost, 
the arteries and capillaries becoming de- 
pleted through partial transfer of the blood 
into the deeper venous trunks, thos^ of the 
splanchnic area in particular. As a re- 
sult, various organs, especially those far- 
thest from the splanchnic area, the brain, 
skin, etc., and those of the thoracic cavity 
are rendered ischemic. Hence the low 
blood-pressure, the feeble heart action 
(due in part to deficient adrenal secretion 
and the resulting deficient contractility of 
its musculature), the deficient respiratory 
activity and the profound adynamia ob- 
served in shock. 



SHOCK. 



121 



Henderson (1908) has attributed shock 
to a loss of carbon dioxide through the 
intermediary of the blood and tissues in 
the course of operations or severe solu- 
tions of continuity. Seelig, Tierney and 
Rodenbaugh (1916) have sustained this 
view by using intravenous injections of 
sodium bicarbonate in shock, the benefit 
obtained being attributed to the power 
of this salt to break up in various tissue 
fluids and thus liberate carbon dioxide. 
More recently fat embolism, acidosis, 
and absorption of toxic products of auto- 
lysis of injured tissues have l)een empha- 
sized as important or essential factors in 
the production of shock. 

Fat embolism emphasized as a 
cause of shock. An undoubted rela- 
tion exists between shock and broken 
bones, particularly when large, as the 
femur. In 8 experiments on cats, in- 
jection of fatty substances into the 
jugular vein induced a clinical pic- 
ture essentially similar to traumatic 
shock in human beings. Fat, ofien 
in large quantities, is known to enter 
the blood vessels in traumatic shock. 
The injurious effects are due to fat 
embolism. W. T. Porter (Boston 
Med. and Surg. Jour., Sept. 6, 1917). 

Where there is low blood-pressure 
in shock, hemorrhage, or gas bacillus 
infection, there occurs a diminution 
in the available supply of alkali and 
hence an acidosis. Operations in 
shock and acidosis cause rapid fall of 
blood-pressure and sudden decrease 
in alkali reserve. Intravenous injec- 
tion of sodium bicarbonate produces 
quick relief of acidosis and a rise in 
the blood-pressure in shocked men 
after operation. Cannon (Jour. Amer. 
Med. Assoc, Feb. 23, 1918). 

Report of investigations showing 
the extreme toxicity of crushed mus- 
cle tissue, even when aseptic. Ab- 
sorption of this muscle autolysate is 
undoubtedly a factor in traumatic 
shock. Crushed tissues in wounds 
should' be cleared out as an emergency 
measure at once, without waiting for 
shock to subside. Dclbct (Bull, dc 
I'Acad. de med.. July 2, 1918). 
Kinetic Theory. — On the basis of some 
1200 experiments, Crile, of Cleveland, was 



led to conclude that the key to shock is not 
in the vasomotor system alone, but in the 
whole motor mechanism of the body. 
Those parts of the body having the great- 
est number of nociceptors — nerve-endings 
through which defensive reactions are 
provoked — and which defend the most 
vitally important structures, are those 
most active in producing shock on re- 
ceiving trauma. Thus, the brain, pro- 
tected as it is by the cranium, is not pro- 
vided with such nociceptors, does not to 
any marked extent awaken shock under 
operation as a rule; the abdominal struc- 
tures, on the other hand, which are richly 
provided with nociceptors, readily pro- 
duce shock when subjected to trauma. 
Now, the physical basis of Crile's theory 
is that when, as is the case under the 
influence of certain anesthetics, ether for 
example, the reflex motor activity which 
normally occurs by stimulation of the 
sensitive nerve-endings fails to occur, and 
there is no response, the impulses which 
reach the cortical centers from the periph- 
eral nerve-endings excite and finally ex- 
haust these centers, and produce in them 
degenerative lesions similar to those that 
histologists long ago identified as the char- 
acteristic cellular lesions of the condition 
known as shock. 

Crile attributes these central morbid 
changes to "work," i.e., excessive oxida- 
tion or febrile process carried on by 
those organs which alone are capable of 
transforming latent into kinetic energy, 
those constituting his "kinetic system," 
the principal organs of which are the 
brain, the thyroid, the adrenals, the liver, 
and the muscles. According to Crile, "the 
brain is the great central battery which 
drives the body; the thyroid governs the 
conditions favoring tissue oxidation; the 
suprarenals govern immediate oxidation 
processes; the liver fabricates and stores 
glycogen; and the muscles are the great 
converters of latent energy into heat and 
motion." Yet it is evident that, as 
Sajous first pointed out in 1903 (when he 
showed that the adrenal secretion circu- 
lated in the brain-cells), it is to the pres- 
ence in excess of the adrenal principle 
that the lesions in the nerve-cells are due, 
for Crile calls attention to the "striking 
fact" that "adrenalin alone causes hyper- 



122 



SHOCK. 



chromatism, followed by chromatolysis, 
and in overdosage causes the destruction 
of some brain-cells." 

But it is not only the stress of trau- 
matism or operative procedures on the 
body which so morbidly affects the nerve- 
cells of the cortex among others, but also 
fear, anxiety, the anticipation of a surg- 
ical operation, emotional excitement, etc. 
All these factors added to the surgical 
traumatism enhance the morbid influence 
of the latter on the nerve-cell. 

How prevent or, at least, reduce these 
effects, which in the aggregate constitute 
the condition we term "shock" and which, 
moreover, reduce the chances of operative 
recovery? This phase of the question is 
considered below in the subsection on 
Prophylaxis, under the title of "anoci- 
association," a term given by Crile to the 
measures through which the pathogenic 
stimuli to the brain may be controlled and 
at least in a great measure prevented. 

PROPHYLAXIS.— The prevention of 
shock during operations is receiving 
greater attention as time progresses. Be- 
fore resorting to any serious surgical pro- 
cedure the volume of urine excreted in 
the 24 hours should be ascertained, and 
an examination of the urine itself made, 
to ascertain that the kidneys are normal. 
This is important, since diseases of 
these organs predispose to shock. The 
excretion of urea should be ascertained, 
for if it falls below 2 per cent, metabolism 
is deficient; such a condition points to 
asthenia which in turn predisposes to 
neurasthenic shock. Violent purging pre- 
disposes to a similar condition; hence, 
while freeing the intestinal contents is 
advisable before operation, it should be 
done only by means of aperients, or rectal 
flushing with saline solution. Some sur- 
geons advise the use of morphine hypo- 
dermically, ^ grain (0.008 Gni.) given 20 
minutes before the operation to quiet the 
patient, besides the influence of whatever 
anesthetic is used in that respect; yet 
others are opposed to opiates in any 
form. The truth lies between the two 
extremes; large doses should be avoided. 

The manner in which the anesthetic is 
administered has much to do with the 
production of shock. To clap a towel 
saturated with ether on the face of the 



already frightened patient and, as far as 
his own experience is concerned, literally 
choke him, and have a rough orderly hold 
his arms and legs to prevent struggling, 
besides advertising the surgeon and his 
assistants as tyros, favor the production 
of precisely the histological changes in 
the central nervous described above under 
Pathology as those peculiar to shock. 
Everything should be done to divest the 
patient of fear by telling him that he 
will soon be asleep, perhaps feel a little 
"stuffy" and the next instant (as regards 
the patient's own experience is concerned) 
awake in his own bed. By thus sug- 
gesting that he will be subjected to no 
suffering either through the anesthetic 
or the operation much can be done to 
pacify him and otherwise avoid shock. By 
using the drop method, Allis's inhaler or 
any other device which insures the pa- 
tient an ample proportion of air, and 
avoiding all rough handling, but little if 
any struggling will occur. 

Another important feature is to main- 
tain the surface temperature to its nor- 
mal level as nearly as possible by covering 
the parts other than those exposed for 
operative purposes, with warm blankets 
and hot-water bottles outside of these 
(and not in immediate contact with the 
skin, which may thus be burnt) to sus- 
tain the heat. The loss of surface heat 
when the body is allowed to become cold 
causes accumulation of the blood in the 
splanchnic area, an important pathologi- 
cal feature of shock. For the same 
reason as little* blood as possible should 
be lost and the operation performed as 
rapidly as safety and thoroughness will 
warrant. 

ANOCI-ASSOCIATION.— W e have 
seen under the heading Kinetic Theory un- 
der Pathology, that Crile means by this 
term a physical exhaustion of the cerebral 
nerve-cells, brought about by abnormally 
active stimuli, trauma, pain, fear, emotion, 
etc. His experiments showed, moreover, 
that the central lesions produced in the 
course of surgical operation could be 
prevented by blocking, as it were, the 
connection between the traumatized part 
and the brain-cells by a technique to 
which he gave the name "anoci-associa- 
tion." Morphine and scopolamine having 



SHOCK. 



123 



been found to conserve the output of 
energy, thus avoiding the transmission of 
excessive stimuli to the brain-cells, they 
form the foundation, as it were, of his 
method. His technique, as exemplified by 
its application in abdominal work, is as 
follows: — 

In patients other than infants, the aged, 
and the asthenic, Crile administers, on an 
average, % gr. (0.01 Gm.) morphine and 
Kno gr. (0.0004 Gm.) scopolamine one hour 
before operation. If local anesthesia alone 
is employed, novocaine in 1:400 solution 
is used by local infiltration. , If inhalation 
anesthesia is employed, nitrous oxide is 
administered, either alone or with ether 
added as required. As soon as the pa- 
tient is unconscious, first the skin and 
then the subcutaneous tissues are in- 
liltrated with 1:400 novocaine. The novo- 
caine is spread by immediate local pres- 
sure with the hand. Incision through this 
anesthetized zone exposes the fascia, 
which is novocainized, subjected to pres- 
sure, and then divided. In succession also 
the remaining muscles or posterior sheath 
and the peritoneum are infiltrated with 
novocaine, subjected to pressure, and di- 
vided within the blocked zone. If the 
blocking has been complete, then within 
the opened abdomen there will be no 
increased intra-abdominal pressure, no 
tendency to expulsion of the intestines, 
and no inuscular rigidity. 

The peritoneum is next everted and in- 
filtrated with a Zl-i per cent, solution of 
quinine and urea hydrochloride, so that 
the line of proposed suture is completely 
surrounded. As before, momentary pres- 
sure serves to spread the anesthetic. This 
infiltration of quinine and urea hydro- 
chloride serves as a block which may last 
for several days. It prevents or minimizes 
postoperative shock. It causes a certain 
amount of edema of tissue which lasts 
for some time after the wound is healed. 

With this technique the relaxed abdom- 
inal wall permits the easy and gentle ex- 
ploration of the entire abdominal cavity. 
If there is no cancer in the field of oper- 
ation and if no acute infection is present, 
then the following regions may be blocked 
as completely and in the same manner as 
the abdominal wall — namely, the meso- 
appendix, the base of the gall-bladder, the 



uterus, the broad and the round ligaments, 
the mesentery, and any part of the pari- 
etal peritoneum. Since operations on the 
stomach and intestines cause no pain if 
they are made without pulling on their 
attachments, no novocaine block is re- 
quired in such operations. 

In operations carried out in this manner 
the closure of the upper abdomen is as 
easy as the closure of the lower; all is 
done with ease in perfect relaxation. No 
matter how extensive the operation, how 
weak the patient, or what part is involved, 
if the technique is perfectly carried out, 
the pulse rate at the end of the operation 
is the same as at the beginning. The 
postoperative rise of temperature, the 
acceleration of the pulse, the pain, the 
nausea, and the distention are minimized 
or wholly prevented according to Crile. 
The cause of the high mortality of 
operations on the gall-bladder is ex- 
haustion and shock, the exhaustion 
of the vital organs of the body. In 
excision of the liver and adrenals 
within a few hours the blood be- 
comes acid. In every case of ex- 
haustion the same changes were 
found in the brain, liver, and the 
adrenals. Postoperative pain finally 
overcomes the margin of safety and 
the patient dies. Neutralization of 
the acids is one of the most impor- 
tant functions of the liver. Every 
response to stimuli produces an acid 
condition. The margin of safety is 
reduced in exhausted patients by 
this acidosis. An increased acidity 
always accompanies inhalation anes- 
thesia. Ether, however, adds an- 
other strain. The liver finally be- 
comes no longer able to neutralize 
the acidity. The only cure for the 
acidosis is prevention, which may be 
largely accomplished by increasing 
the store of energy and preventing 
the waste of it. Glucose and bicar- 
bonate of soda and sleeping in the 
open air will increase the store of 
energy. Morphine does not increase 
the aciditj^ of the blood, but if the 
latter is once produced by emotion, 
starvation, or whatever cause, large 
doses of morphine will then rob the 
body of its power to neutralize the 



124 



SHOCK. 



acidosis. But if given before the 
acidosis occurs, the morpliinc will 
not have anj' effect. Psychic rest is 
obtained by twilight anesthesia. If 
the margin of safety is very narrow 
the operation should be done in two 
stages. Avoidance of injury to the 
splanchnic nerves is insisted upon. 
Crile (X. Y. Med. Jour., July 4, 1914). 

As a preliminary narcotic a com- 
bination of omnopon and scopolamine 
is recommended. It is also valuable 
to give a dose of veronal on the 
evening preceding the operation. The 
writer's method of producing local 
anesthesia for abdominal operations 
is essentially the anesthetization of 
the several nerve-trunks laterally 
upon the abdomen through 5 or 6 
punctures. The solution consists of 
0.4 Gm. (6^2 grains) of potassium 
sulphate and 12 drops of synthetic 
adrenalin to each 100 c.c. of ''/^ 
per cent, solution of novocaine. All 
the tissues, from the skin to the 
peritoneum, should be infiltrated at 
the site of each puncture. In addi- 
tion to this the line of incision is 
infiltrated in a similar manner, and, 
if necessary, additional infiltration of 
the mesenteric attachments, etc., may 
be made. With his technique the 
writer had only 2 cases of post- 
operative shock in well over 2000 
cases. H. M. W. Gray (Brit. Med. 
Jour., Aug. 22, 1914). 

To illustrate the value of anoci- 
association, the writer offers a table 
of all hysterectomies operated on 
since the adoption of the necessary 
technique. Excluding 2 legitimate 
exceptions, the average pulse rate 
for 17 hysterectomies the evening be- 
fore operation was 89; the average 
pulse rate the evening after was 80. 
Some of these patients were very 
much exsanguinated by prolonged 
hemorrhages and some had large 
tumors. The value of the method 
seems incontestable. J. M. Wain- 
wright (Penn. Med. Jour., Dec, 1914). 

The writer advises that glucose 
solution be given as a routine after 
every operation in which one has 
reason to fear more than the ordi- 



nary amount of postanesthetic shock; 
it should be given as a routine in 
every case in which postoperative 
oral feeding may be difficult or in- 
sufficient for a considerable period 
after operation; it should be given 
as an emergency measure either be- 
fore or after operation for the relief 
of an existing or threatened acidosis. 
Burnham (Amer. Jour. Med. Sci., 
Sept., 1915). 

TREATMENT.— Raising the limbs and 
body in such a way as to cause the blood 
to gravitate .toward the head, followed 
by absolute rest and quiet in the recum- 
bent position, and the external application 
of heat (taking care that the skin be pro- 
tected by the blanket or that the water- 
bottles or bags used be wrapped in cloths 
or flannel, lest they burn the patient) 
around the trunk and extremities, are the 
first measures to be resorted to. 

Having treated 6667 wound cases, 
the writer divides shock cases into 3 
major groups, viz., nervous, hemor- 
rhagic, and toxic. A group apart is 
that by exposure or exhaustion. Of 
103 cases of hemorrhagic shock oper- 
ated upon at once, 96 recovered, tend- 
ing to show the advisability of imme- 
diate operative hemostasis in hemor- 
rhage cases, whether shock is or is 
not present at the same time. Under 
nervous shock are placed concussion, 
multiple wounds, or extensive con- 
tusions. In these, the system has 
reached the extreme limit of its re- 
sisting powers and treatment is often 
disappointing. In 4 cases of grave 
nervous shock, however, expectant 
treatment and postponement of oper- 
ation were followed by recovery. In 
toxic shock from absorption, an op- 
portunity for recovery is afforded 
only by prompt removal of the toxic 
tissues. Of 13 cases thus treated, all 
recovered. Gatellier (Presse med., 
Jan. 17, 1918). 
Adrenalin has to a considerable extent 
replaced all other stimulants when in- 
jected in conjunction with saline solution 
into the arterial sytem — for rapid action 
— or into the veins. Its effect ma3^ how- 
e\ er, be evanescent. Two important 
measures developed and found serviceable 



SHOCK. 



125 



during the late war v/ere, intravenous in- 
jection of 6 per cent, gum acacia solution 
to cause a persistent rise in the blood- 
pressure, and the removal of lacerated or 
crushed tissues to obviate shock from 
toxic absorption. 

Locke's solution plus 3 per cent, of 
gum acacia used with success in the 
treatment of low blood-pressure from 
hemorrhage and shock. If there has 
been great loss of blood, the Locke 
must be preceded I:)y an infusion of 
normal saline or sugar solution to 
give the heart fluid to pump on, the 
mucilaginous Locke solution not be- 
ing given in amounts exceeding 150 
c.c. (5 ounces). Delaunay (Lyon chir., 
Jan.-Feb., 1918). 

In shock the catalase of the blood 
and probably of the tissues is de- 
creased, owing to diminished output 
of it from the liver and probably to 
dilution of the blood. Alcohol in 
shock greatly increases the catalase 
of the blood and tissues by stimu- 
lating the liver to increased output. 
The beneficial effect of alcohol in 
shock and general depression is due 
to the increase it causes in the cata- 
lase of the blood and tissues, with 
resulting increase in oxidation and 
decrease in acidosis. Burge and Neill 
(Amer. Jour, of Physiol., Feb., 1918). 

Shocked patients should be placed 
in the quietest available quarters, 
kept darkened, with comfortable beds. 
The bed may be warmed with a 
cradle heated by electricity or an 
alcohol lamp. The arterial pressure 
should be taken every hour. Mor- 
phine is given regularly as it seems 
efifective in raising the blood-pressure. 
Subcutaneous injections of saline 
solution with adrenalin complete the 
treatment, and the patient sleeps. 
When the blood-pressure has im- 
proved to 40 and 70 or 80 mm. Hg, 
then operation is to be considered. 
Necessity for local as well as gen- 
eral anesthesia emphasized. Monery 
and Loml^ard (Arch, de med. et de 
pharni. milit.. Mar., 1918). 

Primary shock tends to lessen 
hemorrhage, and if the patient is 
kept warm and quiet, the Idood-pres- 



sure may return to normal. Partial 
recovery, however, may be followed 
by secondary shock. The best ex- 
planation of this is an accumulation 
and stasis of blood in the capillaries 
— Cannon's cxoiiia. As a result the 
tissues sufifer from oxygen starvation 
and the vasomotor and respiratory 
centers tend to fail. Acidosis is not 
a serious factor in shock. It has 
not yet been demonstrated that the 
symptoms relieved by sodium bicar- 
bonate would not be more definitely 
cured by raising the blood-pressure. 
The main factor in treatment is to 
ensure an adequate supply of blood 
to vital organs. A solution of gum 
arabic (acacia) injected intraven- 
ously in most cases is not inferior to 
blood. A 6 per cent, solution of the 
gum is best, with 0.9 per cent, of com- 
mon salt. Tliis maintains the blood- 
pressure indefinitely. Its value is 
most strikingly demonstrated after 
hemorrhage, though after grave 
hemorrhage blood transfusion is the 
procedure of choice. W. M. Bayliss 
(Brit. Med. Jour., May 18, 1918). 

Traumatic or wound shock is due 
to toxic material from injured tis- 
sues. If the blood-pressure falls 
below 80 mm. Hg, the tissues begin 
to sufifer from lack of oxygen. In the 
treatment, arterial pressure should be 
raised by blood transfusion if it per- 
sists below this critical level. Crushed 
tissue should be removed as soon as 
possible. If a limb is shattered and 
useless, absorption of toxic material 
may be prevented by a tourniquet. 
Amputation should be done proxi- 
mate to the tourniquet and before re- 
moving it. Loss of body heat should 
be checked and normal temperature 
restored by application of heat. 
Since ether lowers the blood-pressure 
in shock, it should be avoided. Nit- 
rous oxide and oxygen should be 
used in a ratio not exceeding 3 to 1, 
preceded by morphine. Deep anes- 
thesia and cyanosis should always be 
avoided. W. B. Cannon (Proceedings 
Amer. Med. Assoc, N. Y. Med. Jour., 
June 14, 1919). 

Crile's technique for the resuscitation 



126 



SHOCK. 



of a patient is as follows: The patient, 
in the prone position, is subjected to 
rapid rhythmic pressure upon the chest, 
with one hand on each side of the ster- 
num, to produce artificial respiration and 
promote circulatory activity. A cannula 
being then inserted into an artery, toward 
the heart, normal saline solution (2 tea- 
spoonfuls of sodium chloride — being care- 
ful not to use the non-deliquescent table 
salt now commonly employed — to the 
quart of warm water) is infused through 
a funnel connected with the ruliber tub- 
ing connected with the cannula. As 
soon as the flow has begun, 15 to 30 
minims (0.9 to 1.8 c.c.) of adrenalin 
chloride (1:1000) are injected at once 
with a hypodermic syringe plunged into 
the rubber tubing, i.e., into the saline 
solution, repeating the dose in a minute 
if needed. The rhythmic pressure on the 
thorax being exerted with maximum ac- 
tivity, plus the powerful contraction of 
the arteries, including the coronaries, 
caused by the infusion, promptly provokes 
a powerful rise of blood-pressure. When 
this attains about 40 mm. the heart re- 
sumes its action, its contractions steadily 
increasing in vigor. As soon as the 
cardiac beats are fairly resumed, the 
cannula should be withdrawn; otherwise 
the marked increase of vascular tension 
will drive a torrent of blood into the 
tube. Pituitary extract in 1:10,000 solu- 
tion seems to sustain the effect on heart 
and circulation longer than adrenalin. 

An important feature of arterial or 
venous infusion is that it should not be 
given rapidly; otherwise an excessive 
amount of fluid will suddenly accumulate 
in the right ventricle, and the heart, al- 
ready feeble, will cease altogether to 
pulsate. 

In prolonged shock, high enteroclysis 
or hypodermoclysis of saline solution is 
indicated. Dawbarn urged that, whenever 
possible, the solution should be intro- 
duced into the median basilic vein, but 
occasionally a vein in the operating wound 
will answer the purpose, or, if necessary, 
the solution may be introduced into the 
common femoral artery with the aid of 
an hypodermic needle attached to a foun- 
tain syringe. Next in order of efficiency 
to intravenous saline infusions are those 



introduced into the rectum. Hypodermoc- 
lysis is the slowest of all the methods. 
The proper temperature for the solution 
according to Dawbarn is about 150° F., 
but this seems high. At least 1 quart, 
and sometimes even 2 or 3 quarts, may 
be injected, providing the precaution is 
taken to introduce the solution slowly. 
The time occupied in introducing the fluid 
should never be less than ten minutes per 
quart. The employment of intravenous 
injections before or at the beginning of 
the operation is not good practice, since, 
by increasing the blood-pressure, it en- 
courages free hemorrhage. 

Valuable for intravenous infusions in 
shock is Ringer's solution, prepared as 
follows: — 

IJ Calcium chloride.. V/> gr. (0.1 Gm.). 
Potassium chloride. 1 gr. (0.06 Gm.). 
Sodium chloride... 90 gr. (6.0 Gm.). 
Heater 1 qt. (1000 c.c). 

M. 

Careful asepsis of the arm, apparatus, 
and solution is important; also the exclu- 
sion of all air from the tube before intro- 
ducing the cannula. The solution should 
be free from solid particles. A probe- 
pointed cannula should always be used. 
The temperature of the solution should 
be about 100° F.; hotter solutions are of 
greater value as a stimulant; an initial 
temperature of 108° to 110° F. is well 
borne. The fluid is cooled from one to 
two degrees by entering the cannula. The 
amount of the solution to be injected at 
one time varies with the rapidity of the 
injection and with the quality and ten- 
sion of the pulse; 1 quart, repeated when 
necessary, is generally better than a large 
amount given at one time. It is of great- 
est value in shock accompanied by hem- 
orrhage. In threatening cases of this 
class direct blood-transfusion should be 
resorted to. 

As regards medical treatment, Senn 
recommended the inhalation of nitrite of 
amyl, and the administration of stimu- 
lants, such as alcohol, hot coffee, and tea. 
Of alcoholic stimulants, hot red wine, 
rum, and brandy-punch deserve the prefer- 
ence. Alcohol in small doses tends to 
raise the blood-pressure by promoting 
oxidation and therefore metabolism in 
the muscular layer of the arteries. 



SHOCK. 



127 



Opium is contraindicated in the treat- 
ment of uncomplicated shock, but atropine 
is recommended by J. C. Da Costa, par- 
ticularly when the skin is very moist. 

Subcutaneous injections of sterilized 
camphorated oil is a valuable cardiac 
stimulant, 3 or 4 hypodermic syringefuls 
being administered every fifteen minutes 
until reaction sets in. Digitalis may be 
used, but it acts slowly in an emergency. 
Strophanthin, using the 1 c.c. (16 minims) 
of the 1:1000 solution in sterile ampoules 
is far more effective. It should be remem- 
bered that in shock the absorption of all 
drugs administered by the stomach or 
rectum, or even injected into the tissues, 
is always slow; hence, care is necessary 
to guard against cumulative action during 
the recovery of the patient. 

Research showing that epinephrin 
has no cumulative action. Its action 
occurs only on direct contact. The 
continual infusion of a weak solution 
of epinephrin may prove a useful 
measure in therapeutics. It is thus 
possible to send the solution continu- 
ously into a vein and thus keep up 
the blood-pressure permanently while 
this is being done — the effect being 
dependent on the concentration of 
the solution, not on the absolute 
amount of epinephrin infused. Straub 
(Mimch. med. Woch., June Zl , 1911). 
Adjuvant measures, such as the inhala- 
tion of oxygen, mustard plasters over the 
heart, the spine and shins; an enema of 
turpentine, hot coffee, whisky or brandy; 
Esmarch bandages around the legs and 
arms or a tight abdominal binder to drive 
the blood toward the vital organs and 
increase the general blood-pressure, are 
all helpful. Crile deems an increase of 
peripheral vascular resistance advantage- 
ous and places his patient in an air-tight 
rubber suit which he inflates with an air 
pump, thus insuring equable pressure 
upon the entire cutaneous surface. Ab- 
dominal massage to favor the better dis- 
tribution of blood from deeper vessels, 
followed by the application of the abdom- 
inal binder referred to above, has been 
lauded as an efficient measure. Galvanism 
of the phrenic has been used to promote 
contraction of the diaphragm and there- 
fore excite respiratory activity. 



ELECTRICAL SHOCK.— The two 

main causes of death from shock due to 
electrical currents, as stated by Spitzka, 
Stanton and Krida and others are cardiac 
fibrillation and respiratory paralysis. The 
cessation of respiration is a secondary 
phenomenon, however, though usually 
simultaneous with cardiac arrest. Com- 
mercial low-tension currents tend to kill 
chiefly by producing cardiac fibrillation. 
As the tension is increased the effect upon 
the heart becomes less pronounced, but 
at the same time the effect upon the 
central nervous system becomes more and 
more certain as the tension is increased; 
so that with high-tension currents death 
is more likely to be caused by respiratory 
failure, although if the contact is pro- 
longed the heart is also stopped. All 
evidence points to the central nervous 
system as being the chief sufferer from 
the effects of currents of more than 4800 
volts. 

Treatment. — Even in cases of good 
contact, as with a high-tension current, 
according to Spitzka, there may be no 
heart paralysis, but only respiratory fail- 
ure, and in such cases respiration may be 
re-established spontaneously or artifici- 
ally. The prognosis is good only in cases 
in which there is some heart action and 
respiration, the former, particularly. 

The stricken individual must, of course, 
be taken out of the circuit, if he be not 
already freed from it. Bystanders can 
do this with rubber gloves, or with hands 
wrapped with thick, dry, woolen material, 
by pulling at the victim's clothing, by 
sticks of wood, or, if in contact with a 
wire, this may be cut with a nipper with 
insulated handles. This must be done 
with caution, as the momentary arc 
formed between the separated ends may 
blind the rescuers. 

The patient should be laid with the 
head a little higher than the body, and 
artificial respiration be begun promptly by 
compressing the thorax about 18 times 
a minute, with the hands applied flat to 
the sides and lower part of the chest. 
The tongue must be drawn forward, or 
the pulmotor may be used if available. 
Massage over the heart, faradization, the 
electrodes applied to the neck ami heart 
region, or adrenalin injection by Crile's 



128 SILVER (SAJOUS). 

method, may be used to stimulate heart silver nitrate with 2 parts of potas- 

action. The epiglottis may be tickled with gj^^^ nitrate, stirring and pouring 

the forefinger. Other methods that have .^^^^ ^^^^jj^_ j^ ^^^^^^ ^^ ^ ^^. 

been suggested are lumbar puncture, , . , . , .... 

venesection, the application of the Leduc '^ard solid, with properties Similar to 

current, and, in the last resort, a high- those of the preceding preparation, 

tension shock of short duration. S. It is sohible in water, but the con- 
tained 66.7 per cent, of potassium 

SILVER.— Silver (argentum) in ,^5^,.^^^ jg ^j^jy sparingly soluble in 

its pure metallic state has a white alcohol. Used externally, 

color and a high degree of luster. It Argcnti o.vidum, U. S. P. (silver 

is unafifected by oxygen or moisture, ^^-^^^^ [AgoO], occurring as a heavy, 

but is readily attacked by sulphur, brownish-black powder, with a me- 

and tarnishes when exposed to air ^^,jj^ ^^^^^ j^ -^ U^l^l^ ^^ reduction 

containing hydrogen sulphide. The ^^^ exposure to light. It is very 

metal itself is not official, but is used slightly soluble in water, to which it 

at times in a colloid state in unofficial ji^^parts an alkaline reaction, and is 

preparations. Of its salts, the nitrate ij^goiubig i^ alcohol. Dose, :^ to 2 

is most largely used. grains (0.03 to 0.13 Gm.) ; average, 1 

PREPARATIONS AND DOSE, grain (0.065 Gm.). 

— Argcnti nitras, U. S. P. (silver ni- Argcnti cyanidum, U. S. P. VIII 

trate) [AgNOs], occurring in color- (silver cyanide) [AgCN], occurring 

less, rhombic plates, with a bitter, as a white, odorless and tasteless pow- 

caustic, metallic taste. It is soluble der, gradually turning brown on expos- 

in 0.54 part of water, and in 24 parts ure to light, insoluble in water and in 

of alcohol. It melts at 200° C. It is alcohol. Formerly used in the prepar- 

rapidly reduced by organic matter in ation of diluted hydrocyanic acid, 

the presence of light, becoming gray Among the unofficial preparations 

or grayish black. Dose, ^ to ^ of silver are the following: — 

grain (0.007 to 0.03 Gm.). ^ Silver citrate [AggCoHgOT], oc- 

Argcnti nitras ftisus, U. S. P. curring as a white, heavy powder, 

(molded silver nitrate, lunar caus- soluble in 3800 parts of water, and 

tic), prepared by melting silver ni- sensitive to light. It is considered 

trate with ^5 its weight of official non-irritating, and has been applied 

hydrochloric acid, stirring, and pour- in substance as antiseptic to wounds 

ing into suitable molds. It occurs and ulcers, and injected in solutions 

as a white, hard solid, usually in of 1 : 4000 to 1 : 10,000 strength into 

cones or pencils, with a caustic taste, the urethra, etc. 

and becomes grayish on exposure to Silver lactate [AgC3H503 + H20], 

light and organic matter. It is in- occurring in crystalline needles, solu- 

completely soluble in water and in ble in 15 parts of water, and turning 

alcohol, the contained 5 per cent, of brown on exposure to light. Used 

silver chloride remaining undissolved, externally (though irritating) for its 

Used externally. powerful antiseptic effect in 1 : 100 to 

Argenti nitras mitigattis, U. S. P. 1 : 2000 solutions. 

VIII (mitigated silver nitrate; mitigated Albargin (gelatose silver). See 

lunar caustic), prepared by melting Albargin in the second volume. 



SILVER (SAJOUS). 



129 



Argentamin (ethylene-diamine sil- 
ver nitrate), a solution of 1 part each 
of silver nitrate and ethylene-diamine 
[CHo(NH2)CH2(NH2)] in parts of 
water, A colorless, alkaline fluid, 
turning yellow on exposure to light. 
Asserted to be non-irritant and more 
penetrating than silver nitrate, owing 
to the albumin-solvent action of the 
containing ethylene-diamine. Used 
in the urethra in 0.25 to 4 per cent, 
solution, and in ophthalmology in 5 
per cent, solution. 

Argonin (silver casein), prepared 
by precipitating an alkaline solution 
of casein with silver nitrate and al- 
cohol. A fine, nearly white powder, 
containing 4.28 per cent, of silver, 
easily soluble in water, forming an 
opalescent solution which clears on 
addition of sodium chloride. Used as 
silver nitrate, generally in 0.5 per 
cent, solution. 

Argyrol (silver vitellin), said to be 
prepared by electrolysis of serum 
albumin, addition of moist silver 
oxide, heating the mixture under 
pressure, and drying in I'acuo. It is 
probably a compound of hydrolyzed 
protein and silver oxide, and contains 
from 20 to 25 per cent, of silver. It 
occurs in black, shining, hydroscopic 
scales, freely soluble in water and 
glycerin, but insoluble in alcohol and 
oils. It is not affected by boiling. It 
is incompatible with acids, and most 
neutral or acid salts in strong solu- 
tion. Used as a non-irritant anti- 
septic in 5 to 25 per cent, solutions 
in urethritis, cystitis, and diseases of 
the mucous membranes of the eye, 
ear, nose, and throat. 

Hegonon (silver nitrate ammonia 
albumose), obtained by treating sil- 
ver ammonium nitrate with albumose. 
A light-brown powder, readily solu- 



ble in water, said to contain about 7 
per cent, of organically combined sil- 
ver. Used as substitute for silver 
nitrate for irrigation purposes in 
1 : 2000 to 1 : 6000 solutions. 

Ichthargan (silver ichthyolate or 
ichthyosulphonate), prepared by neu- 
tralization of ichthyolsulphonic acid 
with silver oxide, and extraction with 
water. A brown, stable powder, with 
a light chocolate-like odor, asserted 
to contam 30 per cent, of metallic 
silver and 15 per cent, of sulphur in 
organic combination, freely soluble 
in water, but incompatible with 
soluble chlorides. It is said to com- 
bine the bactericidal action of silver 
with the penetrating, antiphlogistic 
action of ichthyol. Used in 0.04 to 
0.2 per cent, solution in gonorrhea ; 
3 per cent, solution in posterior ure- 
thritis, and in 0.5 to 3 per cent, solu- 
tion in trachoma. 

Protargol (protein silver salt), pre- 
pared by treating proteins with a 
silver salt, and rendered soluble by 
treatment with a solution of albu- 
moses. A light-brown powder, con- 
taining 8.3 per cent, of silver in 
organic combination, soluble in 2 
parts of water. The solution is not 
affected by alkalies, chlorides, bro- 
mides, or iodides, nor by heat. Its 
precipitation by cocaine hydrochlo- 
ride is pre-vented by addition of boric 
acid. It should not be exposed to 
light. Used as substitute for silver 
nitrate for irrigation purposes in 
1 : 1000 to 1 : 2000 solutions, in 0.25 
to 1 per cent, solutions in acute gon- 
orrhea, and in 5 to 10 per cent, in- 
stillations in chronic gonorrhea, and 
in diseases of the mucous membranes 
of the eye, ear, nose, and throat. 

Colloid silver and its action and 
therapeutic uses have been discussed 



8—9 



130 SILVER (SAJOUS). 

under the heading Collargol, in the Where silver nitrate is to be used 

third volume, to which the reader is locally at intervals in the form of a 

referred. solution, addition of spirit of nitrous 

INCOMPATIBILITIES. — Silver ether is considered of value in pre- 

nitratc is incompatible with organic venting precipitation. The following 

material, becoming transformed into formula is credited to Fox and 

the black oxide of silver or black Higginbotham :— 

metallic silver. With soluble chlo- ^ Argenti nitratis gr. v (0.3 Gm.). 

rides or hydrochloric acid it forms Spiritus athcris nitrosi fSij (8 c.c). 

the insoluble silver chloride. It is Aqncc destillatce f3vj (24 c.c). 

also incompatible with bromides and 

iodides, with alkalies, with acetates, Such a solution may be applied 
chromates, cyanides, hypophospites, freely to the conjunctiva, without 
phosphates, sulphides, sulphates, and neutralization with salt solution, in 
tartrates, with copper salts and fer- all forms of conjunctivitis, from a 
rous and manganous salts, with "^i'd "pink eye" to gonococcal con- 
antimony salts and arsenites, with junctivitis (Valk). 
morphine salts, with alcohol, with Where it is desired to use an oint- 
creosote, with oils, and with tan- *"ent of silver nitrate, the following 
nic acid and vegetable astringent combination may, with advantage, 
preparations. be employed :— 

MODES OF ADMINISTRA- ^ Argenti nitratis gr. xv (1 Gm.). 

TION.-Silver nitrate, when used Acidi borici pulveris.. '^n.s {li) Gm.), 

,, . , ' . . .„ Cerce flava: Sj (30 Gm.). 

mternally, is generally given in pills, q^^. ^^-^^ ^^.. ^^^ ^^^ 

but may also be administered in a yi^ 

solution of 0.2 per cent, strength, c^., •, . ,, , • • 

- , , , , , , Silver oxide is generally adminis- 

preterably through a stomach-tube to ^ . . .,, , 

, , ■' . . . , , ., , tered in pill form, 

avoid precipitation of the silver be- ^, ,< . ,, ., 

, . , , . . ihe organic silver compounds, 

tore It reaches the gastric cavity. , , , 

,,,, , . ." , ,, such as protargol and argyrol, are 

When thus given, it should soon , . n ,, . , • 

r, , , , , r-., used externally, generally in solution, 

after be removed by lavage. Silver .^ i_ i i ^-i 

. ^ ... , ,, , , . , (bee below, under i herapeutics.) 

nitrate pills should be made with ^ 

kaolin or petrolatum, as glucose, PHYSIOLOGICAL ACTION. - 

glycerin, extracts and other materials Locally, silver nitrate is antiseptic 

commonly used as excipients render ''^"^ ^'^'y irritating. It is astringent, 

the' salt inert. The following form- coagulating proteins, and also caustic, 

ula for silver-nitrate pills has been ''^^d^'y destroying soft tissues with 

recommended: which it is brought in immediate 

■D ^ ,. ., ,. ,o/ /rM ^ A contact in concentrated form. It 
tfi Argenti mtratis .... gr. 1% (0.1 Gm.). 

c«^;; c.w/,/,^/;,. .^ coats moist tissues with a tough. 

iioaii sulpliatis ex- ^ 

siccati gr. viij (0.5 Gm.). ^^ite film, and has not much 

KaoUni •. gr. xv (1 Gm.). penetrating power, though Wildbolz 

Aqua destiUata: gtt. x. found 1:1000 to 1:100 solutions to 

Fac. in, pilulas no. xx. penetrate to the subepithelial tissue 

(Each pill contains V12 grain^^.005 Gm.— in the urethra of the dog. In dilute 

of the silver salt). solution it overcomes relaxation of 



SILVER (SAJOUS). 



131 



tissues, and apparently improves 
local nutrition. Its local action, if 
excessive, can be quickly arrested 
with a solution of sodium chloride, 
which precipitates it as silver chlo- 
ride. Applied to the skin, it produces 
a brown and, later, a black stain, on 
exposure to light. 

The "organic" preparations of sil- 
ver, such as argyrol and protargol, 
are not precipitated by protein and 
sodium chloride, and are not astrin- 
gent. Protargol is but slightly irri- 
tant, as compared to silver nitrate, 
and argyrol hardly irritant at all. 
Their efficiency as antiseptics is, 
however, far less than that of silver 
nitrate, for which, in spite of their 
low irritant power, they are not, 
therefore, adequate substitutes where 
a strong antiseptic action is desired. 
Post and Nicoll found the gonococcus 
killed in one minute by 1 : 5000 silver 
nitrate, but only partially inhibited in 
the same period by 10 per cent, pro- 
targol, and hardly at all influenced 
by 10 per cent, argyrol. Similar re- 
sults were obtained in the case of the 
pyogenic streptococcus and the pneu- 
mococcus, except that a 1 : 1000 silver- 
nitrate solution was required to kill 
these organisms in one minute. The 
typhoid organism, on the other hand, 
was killed in one minute only by a 
1 per cent, silver-nitrate solution, 
though succumbing completely in 
the same period to 10 per cent, 
argyrol or protargol. The antiseptic 
action of silver nitrate is due, not 
only to coagulation of the protein of 
the bacteria, but also to a specific 
action of the metal, silver proteinate 
itself being antiseptic. 

The bluish-white pellicle which fol- 
lows the application of silver nitrate 
to the conjunctiva is not coagulated 



albumin, but chloride of silver de- 
posited in the structure of the mem- 
brane. The essential element in 
determining the stain is the soluble 
chlorides of the tissues. It is chlo- 
ride of silver that is decomposed by 
light, not albuminous material. The 
brown stain is either argentous chlo- 
ride or an oxychloride of silver. 
Drops of silver-nitrate solution are 
more potent in causing a stain than 
an application of a stronger solution 
by the brush. 

The penetration of a 20 per cent, 
solution of argyrol as compared with 
weak silver nitrate is practically nil. 
The amount of silver organic silver 
compounds contain is no criterion of 
their therapeutic utility. Argyrol may 
have a mechanical effect, and its 
sedative action is due to the large 
amount of silver it contains, metallic 
silver being sedative in its action. 
Burden - Cooper (Ophthalmoscope, 
Jan., 1907). 

Silver acetate forms a durable solu- 
tion and has the least irritating action 
on the tissues of all the silver salts. 
It is strongly bactericidal. It is im- 
portant to follow its application by 
rinsing with water or with a weak 
salt solution. Schweitzer (Archiv f. 
Gynak., Bd. xcvii, nu. 1, 1912). 

Silver nitrate dissolved in water 
killed the dysentery bacillus in five 
minutes. On the other hand, in 
broth, with the addition of a little 
organic matter and salts, it failed in 
a strength of 1 in 100. The frequent 
failure of silver-nitrate injections in 
dysentery is thus easily understood. 
Albargin gave the best results of any 
of the silver compounds in the pres- 
ence of broth, as it killed the dysen- 
tery bacillus within five minutes in a 
dilution of 1 in 500, but it was less 
efficient in a second trial. Collargol, 
ichthargan, and argyrol had little or 
no action in the presence of broth. 
Rogers (Indian Jour, of Med. Re- 
search, Oct., 1913). 

General Effects. — Taken internally 
in moderate dosage, silver nitrate has 



132 



SILVER (SAJOUS). 



been held to act as a tonic to the 
nervous system, exert a favorable 
influence on the blood, and promote 
constructive tissue metabolism, but 
there exists no delinite pharmaco- 
logic evidence supporting these views. 
Administered subcutaneously or in- 
travenously in poisonous doses in 
animals, its characteristic effects ap- 
pear to be primary stimulation of the 
central nervous system, especially the 
medullary centers, followed by de- 
pression and paralysis; in slower 
poisoning, a marked increase of bron- 
chial secretion, ending in edema of 
the lungs, has been observed. In 
cold-blooded animals,' silver salts are 
said to give rise to convulsions in 
some ways similar to those of strych- 
nine, followed by paralysis. These 
effects have no evident therapeutic 
bearing. Large amounts of silver 
nitrate taken internally produce, by 
reason of their caustic action, a vio- 
lent gastroenteritis, thrombosis of the 
gastric veins, and ulceration of the 
gastric mucosa. 

Absorption and Elimination. — It is 
believed that in man the greater part 
of the silver ingested passes through 
the alimentary tract unabsorbed. The 
remainder is apparently absorbed in 
the form of a solution — none of it be- 
ing found in the gastric or intestinal 
epithelia — and is soon after deposited 
in the tissues in minute granules., be- 
lieved to consist of an organic com- 
pound of silver. That it stays 
imbedded thus indefinitely is sug- 
gested by the fact that the resulting 
pigmentation remains unaltered over 
long periods. 

Fraschetti and others deny that 
any elimination of silver takes place 
in man, either through the kidneys or 
the intestines. 



POISONING.— There are two 

forms of poisoning by silver — that 
following a large single dose (acute), 
and that following the long-continued 
use of small doses (chronic). 

Acute Poisoning. — The symptoms 
of acute poisoning by silver nitrate 
are partly gastrointestinal and partly 
cerebrospinal. Either series of phe- 
nomena may predominate. 

Almost immediately after a poison- 
ous dose, a burning is felt in the 
throat and stomach, and soon aftei' 
violent abdominal pain, with vomit- 
ing and purging, comes on. The ab- 
dominal walls may become hard and 
knotted, more rarely scaphoid. The 
face becomes flushed or livid, and is 
covered with sweat. The expression 
is one of anxiety. When vomiting 
occurs, the ejecta are often brown or 
blackish in color, though sometimes 
white and curdy, especially after 
sodium chloride has been given. The 
lips and mouth are covered with a 
grayish-white membrane, which may 
later change to brown and then black. 
Occasionally, where the poison has 
been ingested in solid form, this 
membrane is absent. 

In some cases the nervous symp- 
toms are severe, consisting of inco- 
ordination, paralysis, and convulsions 
with coma or delirium. The convul- 
sions are generally tetanic, persist, 
according to Rouget, after complete 
abolition of voluntary movements, 
and, according to Curci, are due to 
excitation of the motor cells of the 
cord. 

Collapse follows, because of the 
gastrointestinal corrosion produced, 
and death takes place from asphyxia 
due to central respiratory paralysis, 
accompanied by a profuse flow of 



bronchial secretions. 



causmg 



pul- 



SILVER (SAJOUS;. 



133 



monary edema. In a case reported 
by Ueck coma returned at intervals 
during several days before the patient 
died. 

At post mortem the stomach and 
howels are found corroded, often 
ecchymosed, and with patches of a 
w^hite or grayish color. The lungs 
are congested and the bronchial tubes 
filled with fluid. 

Poisoning by this drug is not com- 
mon. The lethal dose is not certain ; 
30 grains have killed and recovery 
has followed the ingestion of an 
ounce. 

Treatment of Acute Poisoning. — 
The chemical antidote is common 
salt (sodium chloride), which should 
be administered in large amounts. 
Vomiting should then be induced at 
once, as the silver chloride formed is 
soluble in solutions of sodium chlo- 
ride and in the digestive fluids. Lav- 
age of the stomach with a very soft 
stomach-tube may be carefully tried. 
If the stomach cannot be washed out, 
one may give large draughts of salt- 
water and produce vomiting alter- 
nately. Opium and oils may be 
given to allay the irritation, and 
large draughts of milk administered 
to dilute the poison and protect the 
mucous membranes. Mucilaginous 
fluids and white of egg may also 
be used as demulcents. External heat 
should be applied if indicated, and in 
the event of collapse, the customary 
stimulant measures availed of, to- 
gether with artificial respiration. 
Atropine might prove of value to 
counteract the excessive bronchial 
secretion. 

Chronic Poisoning.- — Prolonged in- 
ternal use of any of the soluble salts 
of silver gives rise to chronic poison- 
ing, or argyria. A local argyria, or 



argyrosis, may be caused by the fre- 
quent topical application of a soluble 
silver salt for a prolonged period. 
Discoloration of the eyelids, con- 
junctiva, and cornea has been ob- 
served from the use of silver nitrate 
in the eye, and a similar condition 
noted from its local application in the 
throat, or a blackening of the hands 
from constant working with silver. 
A few cases have even been reported 
of general argyria resulting from 
topical use of silver in the mouth 
and throat. 

General argyria was formerly more 
frequent than now, arising frequently 
from the administration of silver ni- 
trate in epilepsy. The first sign of it 
is the appearance of a slate-colored 
line along the gums, associated with 
some inflammatory swelling. Later 
grayish spots or patches appear on 
the skin and mucous membranes, and 
spread over the whole body until the 
skin has acquired a peculiar bluish- 
slate color, which may become very 
dark. In decided cases, the conjunc- 
tiva and oral mucous membrane are 
involved. In some cases discolora- 
tion is especially marked in the face. 
The silver is found in all the tissues 
of the skin below the rete Malpighii, 
and is deposited mainly in the con- 
nective tissues, the various paren- 
chymatous cells, and epithelia of the 
body escaping the pigmentation. Al- 
though the discoloration is long in 
making its appearance, the deposi- 
tion in the tissues prol^ably begins 
at once, gradual accumulation there- 
after taking place. Especially marked 
deposition occurs in the renal glo- 
meruli, the hepatic and splenic 
connective tissue, the mesenteric 
glands, the serous membranes, and 
the choroid plexus. The connective 



134 



SILVER (SAJUUS). 



tissues throughout the respiratory 
passages and alimentary canal like- 
wise show silver deposition. The 
condition of argyria does not seem 
to affect the general health. 

Two women were workers in silver 
leaf, their task being to cut the leaves 
and lay them in books. One, aged 
27, had wr rkcd steadily for fourteen 
years. The discoloration of the skin 
was first noted when she was 18, and 
it increased steadily for four years, 
then remained the same. It affected 
chiefly the exposed parts and visible 
mucosae. The other patient, 50 years 
old, had begun to follow the occupa- 
tion at 14, and had first noticed the 
discoloration at 21. Both women 
exhibited anemia and disordered di- 
gestion several years before the ap- 
pearance of the argyrosis. The silver 
line on the gums should be watched 
for as a danger signal in subjects 
similarly occupied. Koelsch (Miinch. 
med. Woch., Jan. 30, Feb. 6, 13, 1912). 

Argyria has been induced in three 
months, and after the use of j/2 to 1 
ounce (15 to 30 Gm.) of silver nitrate 
(Cushny). 

Treatment of Chronic Poisoning. — 
Prophylaxis is important. When the 
salts of silver are indicated in a pro- 
longed course of treatment, occa- 
sional discontinuance of the remedy 
is imperative. At the end of the 
third week, the remedy should be 
stopped for one week, and after three 
months a long intermission should 
follow. In the intermissions of treat- 
ment, the patient should receive a 
thorough course of purgatives, diu- 
retics, and baths. Potassium iodide 
may be given with the silver salts to 
expedite its elimination. 

Greater or less success has been 
claimed for various treatments in 
argyria, but in general they are futile. 
Rogers claims that blistering will 
lighten the color, but how it should 



do so is not plain, since the silver 
deposit lies deep down in the skin. 
luchmann recommends the use of 
potash baths and of soap baths, each 
four times a week. The internal use 
of potassium iodide may produce 
some change in the color of the skin, 
but perfect restoration to the normal 
is generally unattainable. 

Report of the case of a young 
woman, supposedly suffering from 
jaundice, which turned out to be 
argyrism following a course of col- 
largol. A dose of 10 grains (0.65 
Gm.) of hexamethylenamine, given 
for a coryza, caused marked improve- 
ment in the patient's coloration. A. 
M. Crispin (Jour. Anier. Med. Assoc, 
May 2, 1914). 

THERAPEUTICS. — Gastrointes- 
tinal Disorders. — Silver nitrate has 
been found of some value in the 
treatment of gastric ulcer. It is often 
given in pill form, sometimes in com- 
bination with extract of hyoscyamus 
or opium. As hydrochloric acid or 
sodium chloride renders it inert by 
precipitation of silver chloride, it may 
prove useless unless its ingestion is 
preceded by lavage of the stomach. 
A 1 in 500 solution of it may then be 
introduced through the tube to the 
amount of Yi fluidounce (15 c.c), and 
in a few minutes lavage with plain 
water repeated. The dose of silver 
nitrate in pill form in these cases is 
M to y2 grain (0.015 to 0.03 Gm.). 
If it is given in solution, sodium bi- 
carbonate may, with advantage, be 
added. 

Pyrosis is frequently relieved by 1- 
grain (0.065 Gm.) doses of silver 
oxide, given in pill form, a half-hour 
before meals. 

In chronic gastritis and gastric 
catarrh, when sour eructations or 
vomiting occur after meals, the ni- 



SILVER (SAJOUS). 



135 



trate in doses of % to H grain (0.01 
to 0.015 Gm.), given an hour before 
meals, sometimes yields good results. 
Forlanini in these cases, when asso- 
ciated with hyperchlorhydria, irri- 
gates the stomach with a solution of 
silver nitrate, 10 to 30 grains (0.6 to 
2 Gm.) to the quart (liter), fol- 
lowed immediately by sodium chlo- 
ride solution. 

Experiments and clinical experi- 
ences showed that silver nitrate has 
the property of increasing the acidity 
of the gastric juice. It is indicated 
in hypochlorhydria and in mucous 
gastric catarrh. It aids in the diges- 
tion of protein. The drug may be 
used to advantage in abnormal fer- 
mentation. It promotes the empty- 
ing of the stomach. These various 
effects were observed with small 
doses (%2 grain — 0.002 Gm. — three 
times a day), as well as with large 
amounts (^ grain — 0.03 Gm. — three 
times a day). Baibakofif (Archiv f. 
Verdauungsk., Bd. xii, nu. 1, 1906). 

Catarrhal jaundice has been re- 
lieved by i/^o-gi'ain (0.005 Gm.) doses 
of silver nitrate. F. Ehrlich has 
recommended (1902) the introduction 
of a 1 per cent, solution of the salt 
into the stomach, after preliminary 
lavage with warm w^ater, in angio- 
cholitis, cholelithiasis, and chole- 
cystitis. The solution is withdrawn 
after one-half to two minutes, the 
process repeated, and washing with 
j)lain water then continued until a 
clear fluid returns. The remedy is 
asserted to act as a cholagogue and 
to relieve the symptoms, sometimes 
after preliminary aggravation. 

Use of silver nitrate recommended 
in all irritative conditions of the 
gastric mucosa with increased secre- 
tion, hyperacidity, nausea, vomiting, 
and pain. In gastric neuroses, how- 
ever, the drug exerts no influence 
whatever. In the hyperchlorhydria 



frequently occurring in chlorosis, 

various diseases of the liver, chole- 
lithiasis, cholecystitis, the early stages 
of nephritis, and reflexly in constipa- 
tion, especially of the spastic type, 
and in mucous colitis, treatment 
should be chiefly directed to the pri- 
mary disease, but for the alleviation 
of the symptoms silver nitrate is 
valuable. 

In benign pyloric stenosis with re- 
tention of the gastric contents and 
decomposition of the retained ingesta, 
the most efifective symptomatic treat- 
ment is thorough lavage followed by 
silver nitrate internally. In fissure at 
the pyloric orifice, lavage followed by 
silver nitrate, a non-irritating diet, 
and olive oil on an empty stomach, 
has never failed, in the author's ex- 
perience, to effect a cure. For the 
pain of gastric ulcer, acute or chronic, 
silver nitrate is superior to any other 
drug. The heartburn, sour eructa- 
tions, headache, and constipation are 
also promptly relieved. 

Silver nitrate is always well borne 
by the stomach. In a case of severe 
hemorrhage from gastric ulcer in 
which the patient suffered intensely 
from sour eructations and laryngeal 
spasm, silver nitrate relieved both 
these symptoms after the second 
dose. In chronic acid gastritis silver 
nitrate acts as in other forms of hy- 
peracidity. In alcoholic gastritis dur- 
ing the hj'peracid stage it should also 
be employed. It is important in all 
forms of gastritis to wash the stom- 
ach thoroughly before the drug is 
given. 

The writer usually gives the drug 
in solution in doses of J4 to ^ grain 
(0.016 to 0.03 Gm.) three times a day 
on an empty stomach. No food or 
drink is followed for half an hour 
after its administration. It is rarely 
necessary to continue longer than 
three weeks, though in rebellious 
cases it may he given for a month 
without danger of argyria. Where 
the intestines react unfavorably it 
should be discontinued at once. H. 
Weinstein (N. Y. Med. Jour., Dec. 
28, 1907). 



136 



SILVER (SAJOUS). 



In ulceration of the cecum or rec- 
tum and in acute and chronic dysen- 
tery, rectal or colonic injections of 
silver nitrate are of value. If the 
cecum be invohcd a large bulk must 
be used to reach the seat of the 
trouble; if the rectum is the part 
affected not more than 4 ounces (120 
c.c.) should l)e used. In either case 
there should be given preliminary 
cleansing injections of warm w^ater. 
If the condition is cecal, one may use 
1 dram (4 Gm.) of silver nitrate to 3 
pints (1500 c.c.) of water; if rectal, 
5 grains (0.2 Gm.) to 4 ounces (120 
c.c). 

If the rectal disturbance is chronic 
and very obstinate, the strength may 
be increased to 5 grains (0.3 Gm.) of 
the salt to 4 ounces of water. A 
solution of common salt should be at 
hand, to be injected if the action of 
the silver is too severe, or to stop 
the action of the remedy when the 
desired effect has been produced. 

The antiseptic and astringent prop- 
erties of protargol proved effective in 
several cases of gastrectasia with py- 
loric stenosis, the fermentation, py- 
rosis, and vomiting being checked. 
Improvement was also noted in 
chronic catarrh, gastric ulcer, and 
even in carcinoma. Several cases of 
dysentery and pseudodysentery were 
rapidly cured by intestinal lavage 
with a 2.6 per cent, solution of pro- 
targol. For the enteritis of children 
y2 to % pint (25U to 300 c.c.) uf a 2 
per cent, solution were employed. 
For gastric lavage a 2 per cent, solu- 
tion is used. It is advisable to wash 
out first with water, then to intro- 
duce 1 quart (liter) of the protargol 
solution. After eight or ten minutes, 
this is again washed out with water. 
For intestinal lavage, a preliminary 
washing with water is not necessary. 
Cantani (Gaz. degli osped.. No. 138, 
1910). 



Nervous Disorders. — Silver has 
l)cen used in anterior and posterior 
spinal sclerosis, and in epilepsy and 
chorea, Ijut with little or no favorable 
eft'ect, except possibly as a general 
tonic. 

In tabes dorsalis Curci has claimed 
good results from the use of a double 
salt, the thiosulphate (hyposulphite) 
of sodium and silver. He gives daily 
from % to 3 grains (0.048 to 0.2 Gm.) 
by mouth or from % to % grain (0.01 
to 0.048 Gm.) hypodermically. He 
asserts that this treatment does not 
cause argyria. 

Surgical Disorders. — Fissures of 
the lips, tongue, nipples, rectum, and 
mucous patches and ulcers of the 
mouth yield readily to applications 
of a 60-grain (4 Gm.) to the ounce 
(30 c.c.) solution of silver nitrate 
applied carefully on a pledget of 
cotton or by means of a camel's- 
hair pencil. In some cases the solid 
stick does better. It is also useful in 
hemorrhage from leech-bites. 

Boils and felons may be aborted 
Ly early application of a strong solu- 
tion of silver nitrate. 

The healing of suppurating ulcers 
and wounds, with large flal)by granu- 
lations, is hastened by an application, 
every day or two, of the solid stick 
or strong solution. The surface of 
indolent ulcers may be touched 
lightly with the solid stick, or a line 
may be traced within and parallel to 
the margin of the ulcer every day or 
two, the ulcer being strapped with 
diachylon adhesive plaster during the 
intervals and the limb dressed with 
a roller bandage. Indolent sinuses 
from buboes or from abscesses may 
likewise be stimulated to healing 
with a strong solution or the solid 
stick. 



SILVER (SAJOUS). 



137 



Powdered silver nitrate recom- 
mended as a means of exciting the 
proliferation of granulations and the 
regeneration of epidermis over open 
wounds and ulcers. As an excipient 
the writer uses fullers' earth (l)olus 
alba), sterilized by heating to 100° 
or 150° C. The mixture should con- 
sist of 1 part of silver nitrate to 99 
parts of the earth. It is dusted on 
the raw surface (not extending over 
the parts already healed over), and 
renewed every second or third or 
fourth day, according to the amount 
of secretion and reaction of the tis- 
sues. When the wound is well on 
the way to epidermization the treat- 
ment should be interrupted from time 
to time and simple aseptic dressing 
applied. The treatment is recom- 
mended especially for burns, and for 
the healing of wounds following 
furuncles and other infective proc- 
esses of the skin. Max. Barnet 
(Miinch. med. Woch., Aug. 30, 1910). 

Bed-sores can sometimes be aborted 
ii, as soon as the surface reddens, it 
is brushed over with a 20-grain (1.3 
Gm.) to the ounce (30 c.c.) solution 
of silver nitrate. This treatment is, 
however, frequently of no avail in 
paralytics. 

Lymphangitis of the forearm re- 
sulting from a poisoned wound of 
the finger may be cured by applying 
the solid stick over the lines of 
inflammation. 

Rovsing prefers silver nitrate to all 
other antiseptics for impregnating 
gauze and drainage wicks, and in the 
preparation of suture material, and 
uses it extensively in his clinic for 
these purposes. 

Spasmodic esophageal stricture lias 
been relieved by the use of a sponge 
probang saturated with a very weak 
solution of silver nitrate. 

Gushing, Halsted, and Lexer highly 
recommend the use of silver foil as 



a dressing for granulating wounds, 
and especially for skin-grafts and the 
incisions in plastic operations on the 
face. The silver leaf acts as an anti- 
Leptic and minimizes scarring. 

The marked tolerance of the body 
tissues for metallic silver has led to 
its use in bone suturing and in the 
preparation of supporting filigree or 
chain for use in cases of ventral 
hernia or other varieties of weakened 
abdominal wall. 

Miller recommends, as productive 
of good scar formation in burns, the 
use of an ointment of protargol, 45 
grains (3 Gm.), dissolved in cold dis- 
tilled water, 75 minims (5 c.c), and 
mixed with 3 drams (12 Gm.) of dried 
wool-fat and 2^^ drams (10 Gm.) of 
petrolatum. 

Silver - foil platelets used over 
wounds where very inconspicuous 
scar is desirable. Wounds thus cov- 
ered remain perfectly dry, even if 
left alone for a week to ten days, 
and epidermization is much acceler- 
ated. In osteoplastic flaps the scars 
are so faint they are scarcely visible. 
Skin grafts may be left untouched for 
a week to ten days, though occasion- 
ally blood and serum collect beneath 
some of the grafts. In granulating 
wounds, healthy granulations are 
rapidly covered over with epithelium 
under the foil, without the formation 
of much granulation tissue. They 
become flatter. The silver foil ap- 
parently has an inhibitory effect upon 
the growth of granulation tissue. 
The surface, when healed, is even 
with the surrounding skin. The sil- 
ver foil is also advised in skin 
sutures beneath plaster-of-Paris casts. 
E. Lexer (Zentralbl. f. Chir., Bd. xlii, 
S. 217, 1915). 

Disorders of the Respiratory Tract. 
— Acute pharyngitis may be aborted 
by the early application of a 60-grain 
(2 Gm.) to the ounce (30 c.c.) solu- 



138 



SILVER (SAJOUS). 



tion. In laryngitis the parts should 
be cleansed with an alkaline solution, 
the parts anesthetized with a solution 
of cocaine, and by the aid of a brush 
and mirror a 10- or 20- grain (0.65 
or 1.3 Gm.) to the ounce (30 c.c.) 
solution of silver nitrate applied to 
the larynx. 

In laryngeal tuberculosis a spray 
of silver-nitrate solution in the 
strength of 3^ to 2 grains (0.03 to 
0.12 Gm.) to the ounce (30 c.c.) may 
be of service. Crocq claims that sil- 
ver nitrate is a valuable remedy in 
pulmonary tuberculosis, promoting 
appetite and digestion and diminish- 
ing cough, expectoration, and night- 
sweats. He administers from % to 
Ys grain (0.008 to 0.02 Gm.) daily, in 
divided doses. It may, with advan- 
tage, be given in a %-grain (0.01 
Gm.) dose combined with 3 grains 
(0.2 Gm.) of Dover's powder. 

In pertussis Ringer advised the use 
of a spray of silver-nitrate solution 
(>4 to 2 grains— 0.03 to 0.3 Gm.— to 
1 ounce — 30 c.c.) to relieve the vio- 
lence of the cough and give the pa- 
tient rest at night. The spray should 
be used when the stomach is empty, 
as it may bring on retching. The 
nozzle of the atomizer should be 
placed well within the mouth to pre- 
vent staining of the skin. 

In atrophic rhinitis and ozena, 
Gleason obtained good results by 
painting a 20 per cent, solution of 
argyrol over the afifected area. 

Ophthalmic Disorders. — ^^Silver ni- 
trate is found useful in ophthalmolog- 
ical practice in all strengths from a 
1-grain (0.06 Gm.) solution to the 
solid stick. 

In simple conjunctivitis, where the 
discharge is profuse, a 2- to 5- grain 
(0.13 to 0.3 Gm.) solution is of value 



In purulent, including gonococcal, 
ophthalmia, when the discharge is 
profuse, the lids should be everted 
and wiped dry, and painted with a 
10- to 15- grain (0.6 to 1 Gm.) solu- 
tion of silver nitrate, immediately 
neutralized with a solution of com- 
mon salt. This should be done once 
daily. 

Protargol is more satisfactory than 
either argyrol or silver nitrate for the 
treatment of acute mucopurulent con- 
junctivitis due to the Koch-Weeks 
bacillus. Argyrol is better than sil- 
ver nitrate. Protargol is perfectly 
safe up to 33 per cent. Its applica- 
tion causes much less pain than sil- 
ver nitrate, but more than argyrol. 
The solution was freely used and the 
excess left in the eye. It was always 
applied with small pellets of absorb- 
ent cotton. Drops for home use were 
always given — silver nitrate in 0.2 
per cent, strength, or argyrol or 
protargol in 5 per cent, solution. 
Butler (Ophthalmoscope, Jan., 1907). 
Many more cases of conjunctival 
argyria result from the use of or- 
ganic silver compounds, such as pro- 
targol and argyrol, than from silver 
nitrate. The writer protests against 
the almost universal use of such com- 
pounds in acute and chronic catarrhal 
conjunctivitis. For these conditions 
a collyrium containing ^ grain (0.03 
Gm.) zinc sulphate and 10 to 12 
grains (0.65 to 0.77 Gm.) of boric 
acid to the ounce (30 c.c.) is more 
surely and promptly efficacious than 
the silver compounds mentioned. S. 
Theobald (Johns Hopkins Hosp. 
Bull, Nov., 1911). 

Granular lids and trachoma are 

benefited by silver nitrate. If there 
is slight discharge the stick should be 
used; if there is copious discharge, 
the use of a 10-grain (0.6 Gm.) solu- 
tion, with neutralization of excess, 
once daily will be followed by 
improvement. 

In blepharitis, Hinshelwood recom- 



SILVER (SAJOUS). 139 

mends the use of argyrol, a strong upon to overcome the more severe in- 

solution of which is rubbed into the fective conjunctival inflammations, 

lid margins after each has been Cutaneous Disorders. — It is claimed 

cleaned of crusts with a camel's-hair that pitting in smallpox may be pre- 

brush cut short. This procedure is vented by puncturing the vesicles, on 

applied at first daily, then every the fourth or fifth day, with a needle 

second or third day. dipped into a 4 per cent, solution of 

In diphtheritic conjunctivitis, after silver nitrate. Others paint the skin 

the absorption of the membrane and with a 1 or 2 per cent, solution, and 

the re-establishment of the discharge, claim that it is equally effective. The 

one may cautiously use silver-nitrate mitigated stick has also been used, 

solution as in purulent ophthalmia. Silver nitrate is also used to de- 

Crede initiated the use of a 1- or stroy parasitic fungi, to cause ex- 

2- per cent, solution, 1 drop in each foliation of the epidermis, or for a 

eye, in the eyes of all newborn in- local stimulant effect. As a caustic 

fants to prevent the occcurrence of it is inferior to several other agents. 

ophthalmia neonatorum. This is, by It has been found useful in some 

many, made a routine procedure, forms of eczema (chronic forms and 

Where all possibility of infection of circumscribed patches), and in reliev- 

the birth canal can be excluded, flush- ing the itching of prurigo and lichen. 

ing out with a saturated boric acid Pruritus ani and pruritus vulvae may 

solution is sufiicient. be benefited by a 4- or 6- grain (0.25 

Silver nitrate cannot be used safely or 0.4 Gm.) to the ounce (30 c.c.) 

in the eye in a solution stronger than solution painted upon the parts two 

3 per cent. A 2 per cent, solution, to four times daily, 

even if neither neutralized or washed The use of silver nitrate has 

out, never causes any irritation. Any also been recommended in lupus, 

solution stronger than 3 per cent., psoriasis, erythema, ringworm, and 

unless at once neutralized with salt erysipelas. 

solution, leaves a faint film of de- Venereal Disorders. — In the treat- 

stroyed epithelium, especially in ment of buboes good results have 

infants (Butler). been reported from injections of a 

The use of silver should be inter- 2 per cent, solution of silver nitrate 

dieted where corneal ulceration ex- in the early stage, 

ists, and when continued use of a In orchitis and epididymitis a 

remedy is desired. The danger of strong solution of the nitrate painted 

permanently staining the tissues must over the scrotum, in the early stages, 

not be forgotten. will often relieve the pain and reduce 

In place of silver nitrate, protargol the swelling. 
(5 to 20 per cent.) and argyrol (5 to Injections of silver-nitrate solu- 
50 per cent.) are often used. Their tions are most useful in the later sub- 
advantages consist essentially of less acute stages of gonococcal urethritis, 
irritant power and greater ease of em- in the strength of 1 part of the salt 
ployment, but their antiseptic power in 500 to 3000 parts of water, bc- 
is decidedly inferior. Neither (espe- ginning with the weaker solution. 
cially argyrol) should be depended Strong solutions used early have 



140 



SILVER (SAJOUS). 



been advised for the purpose of 
aborting the disease ; such use is, 
however, not to be commended. 

Fifty-five men, suffering from gon- 
orrhea, were treated with injections 
of protargol, beginning with y\ io Yz 
per cent., and increasmg m stiength 
to 1 per cent. The patients waslicd 
the urethra out with warm water be- 
fore injecting the protargol. The 
protargol injections were kept at first 
for ten minutes, and later up to thirty 
minutes. Of the 55 patients, only 2 
showed signs of irritation. The aver- 
age time occupied in causing the 
gonococci to disappear finally from 
the discharge w-as 16.3 days. 

Five children with gonorrheal vul- 
vovaginitis were treated with 2 per 
cent, solutions for the acute stages 
and 5 per cent, for the subacute 
stages. The parts were cleaned and 
the solution injected into the vagina 
and kept there for ten minutes, the 
pelvis being raised. None of the 
children complained of irritation. 
Sitz baths were employed as a sup- 
plementary treatment. It took on an 
average of three months befoie the 
last cocci were removed from the 
secretion of the vagina and cervix. 

Protargol yielded as good or better 
results in female gonorrhea than 
other means. The writer employed 
it in solutions of from 5 to 10 per 
cent., and met with no irritating ef- 
fect. Irritant effects are probably 
due to worthless imitations of pro- 
targol, and at times to the solutions 
not being made up freshly with cold 
water. C. Stern (Deut. med. VVoch., 
Feb. 7, 1907). 
The drug is also^ useful in 1 : 500 to, 
1 : 5000 strength in prostatitis, sem- 
inal vesiculitis (after massage), and 
the cystitis of enlarged prostate, or 
bladder stone or tumor. 

Gynecological Disorders. — In ul- 
ceration of the cervix, and in those 
cases of leucorrhea in which the 
cervix is boggy and tender, great 
benefit may follow the application of 



the solid stick within the cervix. 
This procedure is frequently followed 
by headache about the vertex, but 
this can be relieved with 10-grain 
(0.6 Gm.) doses of the bromides. 
Silver-nitrate solutions were used 
very extensively for erosions of the 
cervix, btit other remedies have sup- 
planted them. Vomiting of preg- 
nancy can sometimes be relieved by 
brushing the cervix over with a 60- 
grain (4 Gm.) solution of the nitrate. 

Removal of Silver Stains. — Silver 
stains on clothing may be washed off 
with a solution containing 45 grains 
(3 Gm.) of potassium cyanide, 5 
grains (0.3 Gm.) of iodine, and 1 
ounce (30 c.c.) of water. Another 
method is to dissolve 15 grains (1 
Gm.) of corrosive sublimate in 7 
ounces (210 c.c.) of boiled water, and 
add about 45 grains (3 Gm.) of so- 
dium chloride just before using; the 
stained material is to be placed in it 
for about five minutes and then 
washed two or three times. Hahn 
advises the use of a solution contain- 
ing 75 grains (5 Gm.) each of corro- 
sive sublimate and of ammonium 
chloride dissolved in 10 drams (40 
c.c.) of water. 

When the stains are older they 
may be rubl:)ed with a mixture of 
iodine and ammonia, and the part, 
still wet, then washed thoroughly. 
(When dry, it is highly explosive.) 

Potassium cyanide in solution will 
generally remove stains from the 
fingers or skin. The part should be 
well rinsed immediately afterward. 
Or, the skin may be covered with 
tincture of iodine and then washed 
off with a solution of sodium thio- 
sulphate (hyposulphite). 

L. T. DE M. Sajoits, 

Philadelphia. 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



141 



SINUSES, NASAL ACCES- 
SORY; DISEASES OF.— The nasal 
accessory sinuses, the maxillary, or 
antrum of Highmore, the frontal, 
ethmoidal and sphenoidal, are com- 
monly involved in various disorders : 
acute and chronic rhinitis, the vari- 
ous diseases of childhood, and also in 
pneumonia, influenza and typhoid 
fever, through extension of the infec- 
tion to them. Especially is this apt 
to be the case when septal deviation, 
nasal polypi, turbinate hypertrophy, 
or any other condition capable of in- 
terfering with proper drainage of the 
nasal cavities is present. These con- 
ditions may also provoke chronic in- 
flammation of the sinuses, due to 
accumulation in them of secretions 
containing pathogenic bacteria. It 
may also be caused by chronic ca- 
tarrhal disorders, in which intumes- 
cence of the nasal mucosa is more 
or less permanent, and characterized 
by mucopurulent discharge. The 
source of infection may be located in 
the mouth. Not only may carious 
teeth awaken suppuration of the an- 
trum when, as in the case of certam 
bicuspids and molars, this sinus is 
penetrated by the roots of teeth, but 
also through germs such as the end- 
ameba, pneumococcus and other or- 
ganisms concerned with pyorrhea 
alveolaris. Tonsillar streptococci are 
also thought to prove pathogenic in 
some instances. Syphilis, tubercu- 
losis, carcinoma, sarcoma and other 
destructive processes may also extend 
to, or occur in, either of the sinuses. 
Their bony framework may be in- 
volved in fractures, punctured wounds 
and other traumatisms. 

The pathological changes induced 
are characteristic. Although the mu- 
cosa covering the walls of the various 



sinuses is hardly one twenty-fourth of 
an inch thick, inflammation with the 
accompanying edema may cause it to 
swell to eight or nine times this 
thickness, and to become polyp-like. 
The cavity becomes more or less oc- 
cluded as a resonance chamber, while 
the pressure exerted centrifugally by 
the swollen mucosa upon its walls 
may cause pain, such as that pro- 
duced in the frontal sinus in the 
course of influenza, in the antrum 
during a local inflammation, etc. The 
first mucoid secretion soon becomes 
replaced by mucopus, unless arrested 
in the first stage, owing to invasion 
by pyogenic bacteria and phagocytes. 
While this may occur in any sinus, 
the frontal and maxillary sinus, or 
antrum of Highmore, are the seats of 
predilection for a purulent process. 

Important in this connection is the 
formation of fistulous openings where 
the orifices of a sinus are occluded 
sufficiently by the swollen mucosa to 
prevent the discharge of pus. These 
openings, which occur through the 
thinnest and weakest portion of the 
walls of the sinus, may entail severe 
complications, such as orbital cellu- 
litis, infection of the cranial contents, 
meningitis, periostitis of the osseous, 
tissues adjoining the sinuses, etc. 
Disorders of the nasal accessory 
sinuses, therefore, may prove danger- 
ous to life if neglected. 

MAXILLARY SINUS OR AN- 
TRUM OF HIGHMORE. 

INFLAMMATORY DISOR- 
DERS. — The maxillary sinus may be 
seat of acute or chronic inflammation. 

Acute Inflammation. — This disor- 
der may occur as an extension of 
an acute rhinitis or some inflamma- 
tory disorder of the anterior nares. 



142 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



through the antral opening below the 
middle turbinate, the invasion of 
pus, irritating powders or fumes, in- 
sects, foreign bodies, etc., or occur as 
one of the manifestations of a gen- 
eral infection or toxemia. 

The main symptom is a neuralgic 
pain referred to the cheek of the af- 
fected side. It presents as a charac- 
teristic feature that of being most 
severe in the region of the malar 
bone. If the nasal disorder be such 
as to occlude, by swelling, the ostium 
maxillare, the pain may be severe and 
extend to the orbital region. The pain 
may also affect the upper dental arch, 
even though the teeth of the corre- 
sponding area be normal, owing to 
the tension in the antral cavity. 

All these symptoms become ag- 
gravated where the antral exudate 
becomes purulent. The teeth which 
bury their roots in the lower portion 
of the antrum, and adjoining teeth, 
give rise to severe pain on being per- 
cussed. While a diseased tooth — 
either the second bicuspid or first 
molar — in most instances is a frequent 
cause of antral sinusitis and abscess, 
the determination of this fact should 
be left to a competent dentist. Sound 
teeth have often, been removed by 
incompetent or careless operators. 
' The antrum, owing to its size, is 
the most prolific source of discharge 
of all the sinuses. At first mucoid 
and gelatinous, it eventually assumes 
a mucopurulent character, and is 
voided through the nasal orifice if 
the latter be patent and into the 
nose, and drawn thence into the naso- 
pharynx and expectorated or swal- 
lowed, especially if the nasal passage 
of the corresponding side be ob- 
structed, or if the patient is in the re- 
cumbent position. If the nasal cavity 



is relatively ])atent, the discharge is 
voided anteriorly. It is apt to have 
a foul odor if the cause of the antral 
purulent process be due to diseased 
teeth. When the discharge is pent 
up in the cavity through blocking of 
the nasal orifice a fistuluus opening is 
formed unless the mucopus be arti- 
ficially removed or resolution occur 
spontaneously. The pus may break 
through the nasal wall, forming a 
fluctuating tumor in the middle 
meatus, i.e., Under the middle turbi- 
nate, or through the lower portion of 
the anterior wall of the sinus, and 
escape in the sulcus between the gum 
and the cheek above the first or 
second molar. 

Chronic Inflammation, or Empy- 
ema. — This condition results from 
the acute form when it fails to dis- 
appear spontaneously or remain un- 
treated. The membrane then be- 
comes organized, thickened, irregular 
and polypoid in character, polypi 
sometimes projecting through the an- 
tral orifice beneath the middle turbi- 
nate. In most cases, however, this 
orifice remains patent, and gives pas- 
sage to a free discharge which is 
found in this location, i.e., the middle 
meatus, the elimination of which, an- 
teriorly or posteriorly, is subject to 
the same conditions as in acute sinu- 
sitis. Exacerbations of discharge oc- 
cur along with temporary catarrhal 
symptoms. At times the mucopus 
eliminated is very fetid and imparts 
its fetor to the patient's breath. But 
little, if any, pain is complained of, 
and general phenomena, fever, etc., 
are seldom observed. 

Although some cases may undergo 
spontaneous resolution, the majority 
persist sluggishly during many years, 
undergoing periodical exacerbations 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



143 



of activity. These may occur after 
apparent cure through appropriate 
measures, so that in all cases the 
prognosis should be guarded. 

The diagnosis of antral inflamma- 
tion is not difficult when the location 
of the pain, the presence of pus in the 
middle meatus, and marked sensitive- 
ness of the teeth immediately beneath 
the antrum can be discovered. In 
most cases, however, transillumina- 
tion — a strong electric light being 
placed in the mouth— should be used, 
'showing as it does obstruction to 
light on the diseased side as com- 
pared with the relative free illumina- 
tion on the normal side. It affords, 
at least, corroborative testimony. 
When both antra are diseased, an ex- 
ploratory puncture of the suspected 
antrum beneath the inferior turbinate, 
under local anesthesia, may be re- 
sorted to, but only under strict anti- 
septic precautions. In marked cases 
empyema may be recognized after 
carefully spraying out the nose, by 
causing the patient to bend his head 
over to one side, when a marked ac- 
cumulation of purulent exudation will 
appear in the uppermost nostril. Per- 
cussing the cheek and the teeth may 
elicit suggestive pain. 

The writer questions the efficacy 
of transillumination as the deciding 
factor in determining antral suppura- 
tion, and places more dependence 
upon the suction syringe for diag- 
nostic purposes. The specially de- 
vised needle is readily inserted, and 
nearly a syringeful of water is quickly 
injected into the cavity of the an- 
trum, and at once sucked back into 
the syringe, in order to obtain a 
specimen of the antral contents. In 
a number of cases the writer's sus- 
picions of antral suppuration were 
negatived by excellent transillumina- 
tion, with pupil reflex, whereas, the 



use of the syringe revealed the pres- 
ence of thick pus in greater or less 
amount, or the existence of plugs of 
mucus with or without pus. Wil- 
liams (Jour, of Laryn., Rhin., and 
OtoL, Mar., 1912). 

When from any cause, the nasal 
opening of the antrum becomes oc- 
cluded — through swelling of the nasal 
membrane, polypi, plug of purulent 
material, diphtheritic membrane, etc. 
— all the symptoms, especially the 
pain and swelling, become progres- 
sively worse. The pain finally be- 
comes intense, while the swelling in- 
cludes bulging of all neighboring 
parts, the cheek, palate, gums and 
teeth, eyeball. Symptoms of pyemia, 
chills, sweats, and high fever also ap- 
pear. Thinning of the walls of the 
sinus progresses, however, and finally 
rupture occurs either tlyough the 
palate, alveolar process, orbit or nasal 
cavity. As soon as the pus is evacu- 
ated in this manner all the symptoms 
disappear, apart from those of the 
remainine chronic inflammation de- 
scribed above, and a more or less 
permanent fistula. 

In an examination of 100 heads in 
the necropsy room, the writer found 
that 37 per cent, showed some evi- 
dence of pathological changes in the 
maxillary antra. Of these 37 cases, 
11 were examples of edema; 12 were 
examples of chronic inflammation or 
empyema; 1 was an example of an 
alveolar or dental cyst, and 13 were 
examples of retention cyst. With 
one or two exceptions, all of these 
cases were undiagnosed during life. 
The presence of a large amount of 
pus in 10 out of 12 of these cases of 
empyema may have played an active 
part in causing the death of the pa- 
tients. J. P. Tunis (Laryngoscope, 
Oct., 1910). 

TREATMENT,— In all the phases 
of antral inflammation careful atten- 



144 SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 

tion should be given to the nasal In mild or incipient cases due solely 
cavity. Acute cases and exacerba- to the presence of an inflammatory 
tions of activity in chronic cases may disorder in the cavities, this mild 
often be checked if seen early when treatment, if persisted in, sufifices to 
a nasal inflammatory disorder is the check the antral trouble. It should 
cause, by thorough cleansing with be remembered that polypi, hyper- 
warm saline solution, used freely with trophy of the middle and inferior tur- 
a coarse atomizer, followed by the binal, a foreign body, etc., may prove 
local application, with a' pledget of to be the exciting cause, and that ap- 
cotton on a nasal probe, of the gly- propriate treatment of these condi- 
cerite of iodotannin, which is pre- tions is necessary, 
pared as follows: — The teeth, the roots of which pro- 

B lodi Sss (2 Gm.). ject into the sinus from below, being 

Acidi tannici ,Sss (15 Gm). occasionally the source of antral in- 

^^^ Oss (250 c.c). flammation, they should be carefully 

M. Filter and evaporate to Bij (62 c.c.) examined. Mere sensitiveness un- 

and add i . , 

„, . cler percussion does not warrant a 

Glycerini fjiv (125 c.c.) . i ■ . i . i i 

J' .. ow y o c.c.;. conclusion that they are the source of 

This solution is applied freely over trouble, since inflammation of nasal 
the nasal mucosa, and particularly origin may also cause neuralgia in the 
under the middle turbinate, the area upper dental arch. Teeth should only 
forming the middle meatus into which be drawn, therefore, after an X-ray 
the orifice of the antrum opens. If the bas clearly shown them to be the 
tissues are sw^ollen, the application of cause of the antral disorder. Since 
the above should be preceded by a the recognition of the fact that pyor- 
spray of 4 per cent, solution of co- ibea alveolaris is present in most per- 
caine to contract it and anesthetize it. sons after the thirtieth year, espe- 
This treatment should be carried out cially in view of the resistance of the 
by the physician daily. The patient Endamcba buccalis, a communication 
should then be shown how to use between the mouth and the antrum 
drops into the nose in such a way as should be avoided when at all pos- 
to cause them to bathe the outer wall, sible. It is probable, in fact, that the 
including the space under the middle persistence of empyema treated in 
turbinate, i.e., by bending his head this manner and necessitating a per- 
well over on side of the sinusitis. He manent tube or plug in the alveolar 
should then be ordered to spray his perforation is due to constant reinfec- 
nose carefully night and morning with tion by gingival organisms. When, 
saline solution to cleanse it, then to therefore, the exciting cause is clearly 
apply 5 or 6 drops of 1 : 5000 solution traced to a tooth and it becomes nec- 
of adrenalin into the nostril of the essary to extract the latter to irrigate 
afifected side, and after a few minutes the sinus, it is best to pack the open- 
follow this up with a spray of the i^g with iodoform gauze, and to re- 
following oily solution: — peat the irrigations a few times. If 
Camphor, this does not suffice to cure the antral 

Menthol aa gr. j (0.06 Gm.). disorder — which it often does in re- 

Benzoinol l\] (62 c.c). cent cases — it is preferable to allow 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



145 



the alveolar openingf to close and to 
create an opening through the nasal 

wall. 

The alveolar operation should never 
be done as an operation of choice, 
because it establishes a communica- 
tion between the mouth and a sup- 
purating cavity, and requires the use 
of a tube or plug, which is decidedly 
disadvantageous. The open method 
of doing the canine fossa operation 
is likewise to be condemned on much 
the same grounds. When simple 
irrigation has failed or is not prac- 
ticable, the next step should be a 
large opening in the inferior meatus, 
with removal of a portion of the 
inferior turbinate. If this method is 
employed, very few patients will 
require radical operations. Wells 
(Laryngoscope, Dec, 1906). 

Having encountered a case of fatal 
bleeding in entering the antrum with 
a sharp trocar through the inferior 
nasal meatus, as well as occasional 
infections of the pterygomaxillary 
fossa from excessive momentum of 
the instrument and accidents from 
entrance of the point of the trocar 
into an orbital cell, the writer deter- 
mined to discard the sharp-pointed 
trocar for a smooth-tipped rasp mod- 
elled after those used by Vacher and 
by Watson Williams for penetrating 
into the frontal sinuses. An opening 
large enough to facilitate irrigation 
and avoid premature closure is thus 
made. Luc (Rev. de laryng., d'Otol. 
et de rhinol.. May 15, 1918). 

Although the ostium maxillare is 
most easily reached and penetrated, 
its situation, in the middle meatus, 
i.e., under the middle turbinate, would 
cause a trocar to enter the antrum 
too high up to permit of effective 
drainage through the nose. It is 
preferable, therefore, to puncture the 
thin wall of the antrum which faces 
tlie area beneath the inferior turbi- 
nate. A pledget of cotton well-moist- 
ened, a 10 per cent, solution of 



cocaine having been placed in this 
location and left there about ten min- 
utes, a Coakley or Myles trocar and 
cannula, sterilized by boiling, is in- 
troduced upward and outward under 
the inferior turbinate until one inch 
of the instrument from the lower edge 
of the nostril has entered the nose. 
The trocar is then pushed in through 
the wall into the antrum, then with- 
drawn, leaving the cannula in situ. 
Through it the antrum can be 
drained, then washed out by means 
of syringe with saline solution, and 
again drained dry — a measure which 
often suffices in recent or mild acute 
cases to effect a cure. 

Efforts must be chiefly directed to 
promoting the free and spontaneous 
discharge of pus from the antrum by 
way of the natural ostium, by: (a) 
directing the patient to lie in bed 
with the diseased antrum uppermost; 
(b) the application of cocaine and 
adrenalin solutions to the regions 
around the middle meatus — this may 
be done every four or six hours; (c) 
scarification of these regions; and 
(d) inhalation of mentholized steam. 
If these means fail the antrum should 
be punctured through its inner wall 
in the inferior meatus, and irrigated. 
Tilley (Brit. Med. Jour., Aug. 22, 
1908). 

It should be borne in mind, how- 
ever, that the anatomical relations of 
the frontal and ethmoidal cells with 
the antrum render the latter a sort of 
receptacle for discharges from the 
former. When all these structures 
are diseased, therefore, drainage of 
the antrum in the manner described 
is useful in several ways. 

In those cases in which the entire 
chain of cells is diseased — the an- 
trum, the ethmoidal cells, the frontal 
sinus, and in many cases the sphe- 
noidal sinus also — Jansen has pro- 
posed the extensive external opera- 



8—10 



146 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



tion of laying open the entire chain. 
This operation is only called for and 
only warranted in extreme cases in 
which the cavities are the seat of 
myxomatous or other growths. In 
all ordinary cases of empyema of the 
antrum and ethmoidal cells, asso- 
ciated with nothing more than a de- 
generated condition of the mucous 
membrane that has resulted from a 
prolonged maceration in pus, these 
external operations are, in the opin- 
ion of the writer, unnecessary, for 
the reason that diseased conditions 
of the maxillary sinuses, and also of 
the ethmoidal cells, which are com- 
monly associated with an empyema, 
can be successfully treated by the 
nasal route. J. O. Roe (Annals of 
Otol., Rhin., and Laryn., June, 1909). 

It is sometimes necessary, owing to 
the necessity of keeping the artificial 
opening patent for continued drain- 
age and local treatment, to enlarge 
the opening. This necessitates re- 
moval of the lower anterior portion 
of the inferior turbinate. Wells's op- 
eration is much used for this purpose. 
In this procedure the anterior half of 
the inferior turbinate is first removed 
under local anesthesia with a 10 per 
cent, solution of cocaine and ischemia 
with 1 : 5000 solution of adrenalin by 
means of serrated scissors and the 
snare. An opening is then made with 
a trocar, as explained above, but 
lower down and close to the floor of 
the nose. This opening is then en- 
larged by means of a rasp, used in 
such a way as to extend the opening 
anteriorly, following the line of the 
nasal floor until the junction of the 
nasoantral with the facial wall of the 
antrum is reached. 

Skillern's operation obviates the 
necessity of resecting a portion of the 
inferior turbinate. It is performed 
as follows : After cleansing the nasal 
cavities, anesthesia is secured by the 



application f)f a 20 per cent, solution 
of cocaine and l)y injections of novo- 
caine and adrenalin. A s])indle-shaped 
piece of mucous meml)rane is re- 
moved in front of the inferior tur- 
l)inate by two incisions extending 
through all tlie tissues to the bone, 
and the crista pyriformis is exposed. 
With a chisel, forceps and an electric 
trephine the antrum is then opened, 
flushed out, inspected, curetted, and 
packed loosely with iodoform gauze. 
The gauze is removed in forty-eight 
to seventy-two hours and replaced 
every second day for two weeks. 
This operation enables the operator 
to inspect directly the sinus and to 
follow dc visu local applications to 
any part of the diseased area, includ- 
ing some that are usually resistant 
to treatment. 

In acute maxillary sinusitis one 
should irrigate the cavity as sug- 
gested for empyema; this failing, it 
may be necessary to make a wide 
artificial opening in the lower part 
of the nasoantral wall for ventila- 
tion. In chronic maxillary sinusitis 
one should make a wide artificial 
opening in the nasoantral wall; this 
failing, one should expose the sinus 
through the facial wall, and curette 
the interior. Wells (Med. Rec, Oct. 
29, 1910). 

We have seen that inflammation of 
the mucosa of sinuses causes it to 
thicken greatly and to form polypoid 
projections. In the presence of pus 
this thickened mucosa becomes a 
soggy mass which requires the con- 
servative use of the curette — not the 
vigorous curetting which the late 
John O. Roe has very properly con- 
demned — the snare for polypoid 
masses, and the application of reme- 
dies to all parts of the diseased cav- 
ity. This can only be done by means 
of an operation which enables the 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 147 

operator to reach the sinus through procedure Ly his experience in op- 

the mouth and nose. Such a pro- ^''^ting by the Luc-Caldwell method, 

, , .1 i-> u 11 T when he frequently found a mass of 

cedure, known as the Caldwell-JLuc , . ^. • ,, n r ,u 

granulation tissue in the floor of the 

operation, is begun in the mouth l)y ^^trum which often led to an abscess 

means of an incision in the sulcus be- about the apex of a tooth. A. R. 

tween the gum and lip above the Solenberger (Colo. Med., xii, 269, 

bicuspid and first molar. The perios- 1915). 

teum being detached up to the infra- TUMORS OF THE MAXILLARY 
orbital canal, an opening is drilled SINUS, OR ANTRUM. 

into the antrum as starting for re- Polypi. — The tumors most fre- 

moval, by means of rongeur forceps quently found in the antrum are 

and chisel, of the greater portion of polypi, which, as stated above, often 

the anterior wall of the sinus, forming occur in cases of empyema of long- 

a gap through which the index finger standing. They may either develop 

may easily be introduced. Through in the antrum itself or project out of 

the oroantral opening thus made a the antrum into the nose and develop 

disk of bone about one-half inch in under the middle turl)inate. 
diameter is removed from the nasal Cysts. — These are of two kinds, 

wall, including the anterior half of The one, developed from the mucosa 

the inferior turbinate. of the antrum, gives rise to period- 

Besides permitting any curetting or ical discharges of a. watery, odorless 

snaring that may be necessary, this fluid, and, when sufficiently large, to 

operation affords a free field for local deformity and' bulging of the affected 

treatment. Irrigations with saline side. 

solution, followed by insufflations of The second variety arises from an 

iodoform over all parts of diseased alveolus, and is due to cystic degen- 

surface, a-nd packing with iodoform eration of the peridental membrane. 

gauze daily for ,a week or ten days, It causes erosion of the antral wall, 

will usually deal effectively with a penetrates the antrum by pushing its 

case of empyema. The oroantral open- mucosa before it, then grows rapidly, 

ing may be closed by sutures after soon filling the cavity, and causing 

free drainage and the use of the cu- deformity of the face and palate on 

rette or snare, and the medical treat- the corresponding side. A character- 

ment carried on through the nasal istic crackling sensation is elicited by 

opening. At times stimulation of the compressing its outer wall. If it 

antral membrane is necessary; this ruptures it yields a greenish, thick, 

may be done by using a spray of 25 odorless fluid, containing, as a rule, 

per cent, solution of argyrol. Irritant cholesterin crystals. Unlike the other 

antiseptics and astringents are more variety, there is no discharge in the 

harmful than beneficial in antral nasal cavity, unless it ruj^tures, when, 

diseases. becoming infected, it simulates an 

Removal of a tooth, unless it can empyema, giving- off a fetid discharge, 
be demonstrated to be the^ offending Osteoma'!— In this form of tumor. 

member, is bad practice. The author ^ i t i i 

, , .... svmptoms are only awakened when 

advocates an examination through a - ' 

sufficiently large opening in tlic an- the neoplasm has grown sufficiently 

terior wall. He was led to adopt this to compress the uasal wall, and thus 



148 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



gradually decrease the lumen of the 
nasal passage of the correspondintj 
side. No pain is experienced until a 
large size is attained, and no dis- 
charge of an abnormal character is 
complained of. An exploratory needle 
or trocar thrust into the tumor is ar- 
rested as soon as the mucosa is pene- 
trated, and transillumination shows 
complete darkness as compared with 
the other side. 

Malignant Tumors. — Sarcoma and 
osteosarcoma are the growths most 
commonly observed in the antrum. 
Cases of psamnio- sarcoma, epithelioma, 
perithelioma (Sakai) and endothelioma 
have been reported. These tumors, 
particularly sarcoma, grow with rela- 
tive rapidity and usually cause lan- 
cinating pain and considerable swell- 
ing. After filling the antrum, they 
penetrate into the nasal or naso- 
pharyngeal cavity, rapidly decreasing 
their lumen and giving rise to a mu- 
copurulent discharge often streaked 
with blood and detritus, and giving 
off a foul odor. The glands behind 
the angle of the jaws are enlarged 
soon after the nasal cavities are 
invaded. 

Unique case, as a careful search of 
medical literature revealed none like 
it, of a calculus made up almost 
entirely of a calcium phosphate and 
found in the course of an operation 
for a squamous-celled epithelioma 
involving the antrum of Highmore. 
N. H. Carson (Interstate Med. Jour., 
Mar., 1913). 

TREATMENT.— The removal of 
polypi from the antrum requires, as 
previously stated, sufficient room to 
render the use of the curette or snare 
possible. For this purpose the Cald- 
well-Luc operation affords the re- 
quired room. This applies also to the 
removal of ordinary cysts. As regards 



the cysts of dental origin an injection 
of a 2 per cent, solution of phenic acid 
into the cyst, through an incision 
above the diseased tooth if necessary, 
causes shrinking and disappearance. 
If the growth cannot be reached, the 
Caldwell-Luc buccal opening should 
be practised, and the cyst removed, 
including the offending tooth, if 
necessary. 

Osteomata can only be removed sat- 
isfactorily by dissecting up the facial 
tissues from the antral wall and by 
means of chisel and gouge insure 
complete excision of the growth. 
This operation, which should, of 
course, be done under general anes- 
thesia, is but rarely followed by 
recurrence. In malignant growths re- 
moval of the affected superior maxilla 
alone affords any hope of recovery. 

FRONTAL SINUS. 

INFLAMMATORY DISOR- 
DERS. — The frontal sinus may be 
the seat of acute and of chronic 
inflammation. 

Acute Inflammation. — In this con- 
dition, especially when suppuration is 
present, there is more or less severe 
pain between and above the eyebrows, 
which presents the characteristic of 
being increased by leaning forward 
and by coughing and of being so ag- 
gravated on blowing the nose that the 
patient is apt to avoid emptying the 
nasal cavity properly. Percussion 
over the sinus also causes pain ; this 
is likewise the case when pressure is 
exerted under the frontal sinus, i.e., 
on the orbital plate below the edge 
of the orbit under the supraorbital 
foramen. The whole superciliary re- 
gion, especially over the course of the 
supraorbital nerves, is hyperesthetic. 
In mild cases a sensation of fullness 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



149 



and weight in the frontal region is 
alone experienced. The discharge, at 
first serous, may become bright yellow 
and purulent, and pass down into 
the nasal cavity between the middle 
turbinate and the outer wall of the 
cavity, but if the orifice, the infun- 
dibulum, be obstructed, the sinus is 
distended, and a fistulous opening 
may form, or the abscess may break 
into and invade the neighboring an- 
terior ethmoidal cells. 

CHRONIC INFLAMMATION.— 
Chronic inflammation of the frontal 
sinus may occur as a result of acute 
inflammation of the sinus, or, through 
extension, a chronic ethmoiditis, in 
which the anterior ethmoidal cells are 
ruptured through distention and allow 
their purulent contents to penetrate 
into the frontal sinus. An antral em- 
pyema may also act as primary cause. 
The antral mucosa undergoes poly- 
poid thickening, and sometimes be- 
comes the source of polypi which 
project into the nasal cavity and 
cause considerable annoyance. In 
most cases but little pain is com- 
plained of, a sensation of fullness or 
pressure above the brow, and some 
tenderness over the latter, being usu- 
ally experienced. Swelling or bulg- 
ing over the frontal sinus may also 
occur. There is, in most cases, con- 
. siderable discharge which may be 
voided anteriorly or posteriorly, the 
patient complaining that he is suffer- 
ing from "nasal catarrh." Periodical 
discharges of mucoserous or muco- 
purulent fluid may afford considerable 
relief. 

Pent up, the discharge may cause 
rupture of the sinus and pass into the 
orbit, the nasal cavity, the dura 
mater, causing meningitis ; or the 
lymphatics may serve as carriers of 



pathogenic bacteria or purulent ma- 
terials to the meninges. Edema and 
redness of the upper eyelid is usually 
present. Fistulous openings may also 
form anteriorly, i.e., through the an- 
terior wall of the sinus, opening above 
the inner canthus. The pain, when the 
suppuration is confined in the latter, 
is severe and constant, and often as- 
sumes a neuralgic or boring charac- 
ter. Or, persistent headache with 
insomnia may occur. The frontal re- 
gion becomes markedly bulged, and 
in extreme cases one or both eyeballs 
may be displaced, causing diplopia. 
Even amaurosis has been caused 
through persistent pressure upon the 
eyeball. Systemic phenomena, sug- 
gesting pyemia chills, sweats, fever, 
etc., are often observed in severe 
cases. Persistent pressure may so 
reduce the thickness of the anterior 
walls as to make it possible some- 
times to obtain fluctuation and crack- 
ling. Unless the pent-up discharge 
be removed surgically, rupture may 
occur and awaken the dangerous com- 
plications recited above. 

The presence of a frontal abscess 
is not definitely shown by trans- 
illumination. An X-ray photograph 
affords a clear idea of the topography 
of the sinus, the diseased side appear- 
ing relatively dark. If the same area 
also appears dark under transillumi- 
nation, the diagnosis of local disease 
is correspondingly strong. This is 
further strengthened if, on examining 
the nasal cavity, pus or polypi are 
found beneath the middle turbinate 
into which the infundibulum, the 
elongated outlet of the frontal sinus, 
opens. 

TREATMENT. — An important 
feature of acute frontal sinusitis is 
that it is apt to develop in conjunc- 



150 



SINUSES, xNASAL ACCESSORY; DISEASES OF (SAJOUS). 



tion with the acute rhinitis attending 
various febrile disorders. In influ- 
enza, for instance, the pain aljout the 
brow is due to this cause. The local 
process is simply that of occlusion of 
the infundibulum, through swelling 
of its mucosa. The escape of the 
mucus to the nasal cavity being pre- 
vented, distention of the sinus and 
swelling of its mucosa follow, giving 
rise to the painful sensation. The 
aim should be, therefore, to free the 
sinus by opening it. This may be 
done with a spray of warm saline 
solution directed upward under the 
middle turbinal. A 2 per cent, solu- 
tion of cocaine, containing 2 drams (8 
c.c.) of the 1 : 1000 solution of adrena- 
lin to the ounce (30 c.c.) is then 
sprayed in the same region, the pa- 
tient leaning fonvard while using the 
spray in order to cause the fluid to 
flow into the infundibulum. After a 
few minutes, considerable relief will 
be experienced, owing to contraction 
of the tissues around the infundib- 
ulum, and a flow of mucus will soon 
follow. Repeated every two hours, 
this procedure will prevent suffering, 
unless polypi or hypertrophies pre- 
vent access of the remedial fluid to 
the frontal passage. 

In a number of acute cases marked 
relief was obtained — because of the 
free rhinorrhea set up — from the in- 
tranasal use of the following solu- 
tion: Mercuric iodide, 1 Gm. (15 
grains); potassium iodide, 4 Gm. (1 
dram), and water, 100 c.c. (iVs 
ounces). D. Macfarlan (Jour. Amer. 
Med. Assoc, Jan. 3, 1914). 

The patient should be kept at rest 
and placed on a light diet, avoiding 
stimulants, coffee, etc.. to keep the 
blood-pressure within its normal 
limits. Drugs, such as opium, bella- 
donna, etc., which tend to cause dry- 



ness of the mucous membranes, 
should be avoided. Saline purgatives 
should be used if ihc bowels are not 
free. The biniodide of mercury in 
^20-grain (0.003 Gm.) doses three 
times daily shortens the purulent 
process by enhancing the antitoxic 
.'uid bactericidal properties of the 
blood. Hexamethylenamine, 4 grains 
(0.26 Gm. ) three times daily, has 
been recommended. 

The same local treatment some- 
times proves useful in chronic cases, 
when used four times daily, the 
fourth time on retiring, giving also 
the biniodide of mercury. If it fails, 
the frontal sinus cannula should he 
introduced into the sinus, and the 
frontal sinus washed out daily with 
saline solution, the patient being 
taught to use the cannula and to 
wash out the sinus also on retiring. 
In most cases the cannula is easily 
introduced by passing its curved tip 
upward under the anterior end of the 
middle turbinate. When this does 
not suffice to insure proper drainage 
and restore the sinus to its normal 
condition, removal of anterior portion 
of the middle turbinate with cutting 
forceps is indicated. This provides 
free access to the sinus for local treat- 
ment by injection of 20 to 30 minims 
(1.25 to 1.8 c.c.) of a 10 per cent, 
solution of argyrol after careful wash- 
ing with the warm saline solution. 

When these less radical methods 
prove insufficient for proper drainage, 
opening of the sinus through its an- 
terior or inferior wall becomes neces- 
sary. When this is done, enough of 
the wall must be removed to permit 
a thorough examination of the cav- 
ity and enlargement of the naso- 
frontal duct to an extent sufficient 
for free drainage into the nose. If 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



151 



operation is delayed too long, the 
continued pressure may cause rup- 
ture through the floor into the orbit 
or through the posterior wall of the 
sinus into the brain-cavity, with con- 
sequent purulent meningitis or brain 
abscess. 

The surgical treatment of frontp- 
ethmoidal sinusitis has progressed 
through many ch.nges. To cure 
frontal sinusitis and prevent its re- 
currence it is necessary to eradicate 
the cavity. The ethmoid is approached 
by the endonasal route so that when 
the frontal sinus is opened all that 
remains to be done is to enlarge the 
nasofrontal canal at the level of the 
infundibular region for free drainage. 
The modification of the Ogsten-Luc 
operation is less mutilating and fur- 
nishes excellent drainage. A rather 
large bony opening is made at the 
level of the frontal boss in order that 
the whole frontal cavity may be in- 
spected and curetted completely. E. 
J. Moure (Laryng., xxxi, 479, 1921). 

Such operations should be per- 
formed only by a highly trained 
specialist, as otherwise they are 
fraught with danger. 

The indications for the external 
operation of the frontal sinus may 
be divided into absolute and relative. 
Absolute indications are: (1) Where 
the disease has made such progress 
as to seriously threaten some neigh- 
boring organ, and even life itself is 
threatened, or there are actual cere- 
bral and orbital complications. (2) 
When the subjective symptoms are 
severe enough to interfere with the 
business pursuits of the patient. (3) 
When severe exacerbations occur. 
(4) In abscess or fistula formation. 
Relative indications are: (1) When 
the headache continues with no ap- 
parent change in the amount or con- 
sistency of the secretion. (2) When 
despite frequent irrigations the pus 
continues fetid, even though dimin- 
ishing slightly in amount. (3) When 
the X-ray shows a large sinus with 



many ramifications and the disease 
does not appear to yield satisfactorily 
to internal treatments. 

As to the type of operation, this 
is often determined by the patholog- 
ical change present or the anatom- 
ical configuration of the sinus. Other 
things being equal, the writer per- 
forms his modification of the Jansen 
operation, in which he can spare the 
anterior wall, but obtain the requisite 
space. This is done by resecting the 
superior internal portion of the mar- 
gin of the orbit and the floor of the 
sinus, thus exposing the entire lower 
portion or funnel of the frontal sinus. 
After this has been done the usual 
procedures are followed, i.e., removal 
of diseased mucosa, the ethmoid cells, 
and, if necessary, the sphenoid is 
opened. The communication with 
^the nose may be enlarged to any 
desired size by merely removing the 
orbital plate piecemeal with the bone 
forceps. The wound is closed and 
dressed in the usual manner. R. H. 
Skillern (Laryngoscope, xxv, 212, 
1915). 

The writer believes that the exter- 
nal (Killian) operation on the frontal 
sinus has not fulfilled the brilliant 
hopes that were raised at the time 
of its introduction, and that the ear- 
lier successes reported have been 
discounted by instances of septic 
osteomyelitis, an almost universally 
fatal complication, even in the hands 
of skillful operators. In many cases 
very grave deformity has resulted, 
and, in addition, the operation often 
fails to give the relief sought. 

Intranasal methods for obtaining 
drainage and space for lavage by the 
removal of the anterior end of the 
middle turbinate have long been 
practised and are of value, but are 
often, also, insufficient to effect a 
cure. To Ingals is due the credit of 
introducing the method of following 
up the frontonasal duct and entering 
the sinus through the normal ostium. 
All subsequent intranasal methods 
are developments of the Ingals op- 
eration. The author believes most of 
these to be dangerous, and advances 



152 



SINUSES, XASAL ACCESSORY; DISEASES OF (SAJOUS). 



his own operation as being compara- 
tively safe. He begins lielow and an- 
terior to the middle turbinate and 
continues upward to the frontal 
sinus, "without destroying any part 
of the vertical plate of the ethmoid," 
a point he thinks of much impor- 
tancCj since he says it does not in- 
volve fracturing through the vertical 
plate in close proximity to the crib- 
riform plate and laying open venules 
and lymphatics in this dangerous 
area to infection. The writer's op- 
eration may be done with cocaine, 
but he much prefers general anesthe- 
sia. His technique is simply to cut 
through the most anterior attach- 
ment of the middle turbinate with a 
conchotome and continue biting up- 
ward through the anterior cells to 
the crista nasalis. In the same man- 
ner the cells lying behind the duct 
are then removed to any necessary 
extent. Sounds are passed into the 
sinus and all projecting edges re- 
moved. Often this will suffice, but 
if enough room has not been secured 
by these measures, the nasal crest 
may be rasped away, but it is much 
preferable to use a guarded burr for 
this purpose. The advantage claimed 
for the burr is that the mucous mem- 
brane of the posterior wall is left 
intact and the bone only laid bare 
anteriorly. 

He advocates the use of from 30 
to 50 c.c. of polyvalent antistrepto- 
coccus serum immediately before the 
operation, followed by the adminis- 
tration of sensitized vaccines. Sounds 
should also be passed at regular in- 
tervals after the operation to insure 
the permanency of the opening made. 

Over one hundred frontal sinuses 
have been treated in this way by the 
author, who claims that many have 
been cured and nearly all relieved. 
In a few instances he was unable to 
reach the sinus pernasally. P. Wat- 
son-Williams (Surg., Gynec. and Ob- 
stet., from Lancet, July 15, 1915). 

As stated by Shurly some years 
ago, the surgery of the frontal sinus 
will become more conservative as 



our knowledge grows. The relief 
should come, not through surgery 
alone, but from prophylaxis and the 
successful abortion of the common 
colds. An important feature of these 
cases is tlie careful treatment of 
chronic rhinitis in any of its forms 
(see Nose, Diseases of, in the sev- 
enth volume). A change to a semi- 
tropical climate, such as that of 
I'lorida or Southern California, pref- 
erably near the seashore, sometimes 
proves curative. 

TUMORS OF THE FRONTAL 

SINUS. 

Mucocele. — Mucoceles are but re- 
tention cysts formed by closure of 
the infundibulum and the accumula- 
tion of the exudate within the sinus. 
This gives rise to a feeling of disten- 
tion and neuralgic pain in the supra- 
orbital region, which is itself exceed- 
ingly sensitive to palpation. In some 
instances there is formed a polyp- 
like tumor of the swollen mucosa 
which is visible under rhinoscopic 
examination if a very small mirror be 
used, and sufficient often to form a 
myxoma-like tumor under the middle 
turbinate. In others, the pressure is 
also exerted anteriorly or laterally 
and by eroding the orbital wall 
causes displacement of the eyeball. 

Case of an unusually large muco- 
cele of the frontal and ethmoidal 
cells. The patient, a woman 69 years 
of age, was first examined November 
25, 1914, for a supposed growth of 
the left orbit. There were two lumps 
the size of beans just below the 
brow, which coalesced and formed a 
marked prominence, displacing the 
eye outward and downward. There 
was no pain or evidence of inflam- 
mation, nor any appreciable derange- 
ment of vision. She gave a history 
of having had nasal catarrh several 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



153 



years before, but had not been trou- 
bled since. Uncorrected vision was 
5/7.5 in the right, 5/9 in the left. The 
fields of vision were normal. The 
proptosis of the left eye was about 
1.5 cm. in advance of the right. 

The periocular swelling eventually 
reached the size of a hen's egg and 
was systic to the touch. The rhino- 
logical examination showed a large 
cystic mass that had apparently de- 
stroyed the orbital wall of the frontal 
sinus. The left nasal fossa was free, 
although the lateral wall seemed 
more prominent than usual in the 
agger nasi region. Transillumination 
of the antrum was negative. The 
X-ray report was that the supra-or- 
bital ridge was completely absorbed 
and the sinus enlarged upward on 
the frontal bone. 

An external operation was per- 
formed with the incision through the 
brow and the sac exposed, the walls 
of which were found to be composed 
of thickened periosteum, which was 
filled with the frontal sinus contents. 
The bone of the anterior wall and 
floor of the sinus had entirely eroded 
away, and the ethmoid cells were 
exposed on the removal of this sac. 
These were partially exenterated and 
drainage established into the nose. 
The posterior wall was also eroded 
and the meninges were separated 
from the sinus only by the perios- 
teum. Healing was prompt and with- 
out incident. In two weeks the 
wound was closed and the excursions 
of the eye were normal. Uncorrected 
vision was now 5/7.5 in each eye. W. 
C. Posey (Ophthal. Rec, xxiv, 116, 
1915). 
Cysts. — Cysts similar to those ob- 
served in the maxillary sinus have 
occasionally been observed in the 
frontal sinus. They contain a green- 
ish or brownish viscid fluid, some- 
times v^^ax-like, which is voided with 
difficulty when they rupture. A very 
gradual swelling, accompanied by lit- 
tle or no pain about the brow, is 
about the only symptom noted, even 



though the osseous walls of the cyst 
are being thinned by pressure until 
palpation and slight compression im- 
parts a crackling, parchment-like sen- 
sation to the finger. 

Case of a cyst of the frontal sinus 
in a man of 56. The tumar had been 
growing fifteen years, the patient 
having refused operation until it 
measured 38 by 35 cm. An incision 
released 1800 Gm. of a reddish 
brownish fluid. The brain was found 
much compressed, while the bone 
had been worn away. The case is 
remarkable from the absence of 
brain symptoms and of pain or other 
sensation except the discomfort from 
the large tumor, although after its 
removal there was room for the fist 
between the skull and the brain. 
Herzenberg (Deut. med. Woch., Nov. 
4, 1909). 

Osteoma. — Primary osteoma of the 
frontal sinus is rarely encountered. 
It grows very slowly, and finally pro- 
duces considerable deformity of the 
face. At first the growth is insidious, 
but after a time neuralgia becomes a 
leading symptom, with, perhaps, un- 
due sensitiveness over the growth ; 
however, even under pressure, the 
latter conveys to the finger a sen- 
sation of flinty hardness. Trans- 
illumination shows darkness on the 
affected side, but the growth is sel- 
dom sufficiently circumscribed to en- 
dow this diagnostic resource with 
much value. An X-ray plate affords 
aid only within the same limitation. 

Case of osteomalacia in a married 
woman, aged 35, who had been op- 
erated on fifteen years previously. 
The main orbital projection had been 
removed, with marked relief to the 
orbital symptoms. The patient con- 
sulted the writer because of severe 
pain, obstruction of the right nos- 
tril, and gradual protrusion of the 
right eyeball. The radiograph gave 
most valuable information as to the 



154 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



position and extent of the exostosis. 
A curved incision was made from the 
middle of the right ej^ebrow to the 
right ala nasi. The expanded and 
thinned covering of bone was clipped 
off, and, the pedicle of the growth 
attached to the posterosuperior wall 
of the frontal sinus having been di- 
vided, the whole growth was re- 
moved with comparative ease by- 
means of a strong pair of forceps. 
The growth measured 2^ inches in 
length and 1J4 inches in breadth. 
The wound healed by first intention. 
Jones (Brit. Med. Jour., Nov. 17, 
1906). 

In examining the frontal sinus, an- 
trum and ethmoidal cells, the writer 
takes first a lateral view of the face, 
and, secondly, an anteroposterior pic- 
ture with the tube behind the head 
and the plate in front. Anteropos- 
terior pictures of the head seldom 
show as well in print as in the orig- 
inal print or negative, which is best 
examined by transmitted light in a 
negative examining box. Tousey (N. 
Y. Med. Jour., Mar. 28, 1908). 

Malignant Tumors. — Although all 
forms of malignant growths in this 
location have been recorded, epithe- 
lioma and sarcoma are those most fre- 
quently observed. The symptoms 
being practically those of chronic 
sinusitis, empyema, and mucocele, an 
early diagnosis is difficult. Even the 
advanced signs, such as prominence 
of the eyeball with diplopia, amauro- 
sis and pain, are common to other 
disorders. Suggestive; however, is a 
more or less foul discharge from the 
nose when it is streaked with blood 
and detritus, and traced with pre- 
cision to the infundibulum, or, in the 
case of sarcoma, recurrent hemor- 
rhages, traced to the same region. 
Swollen glands behind the angle of 
the jaw may suggest malignancy. 

TREATMENT. — Mucoceles' and 
cysts can sometimes be opened in the 



nasal cavity and its contents evacu- 
ated. This is facilitated by causing 
constriction of the surrounding tis- 
sues by means of a 4 per cent, solu- 
tion of cocaine, followed by spraying 
with saline solution. In most cases, 
however, the contents are gelatinous 
and cannot be evacuated without an 
incision over the projecting wall, re- 
secting a sufficient portion to allow 
curetting and packing with iodoform 
gauze. 

Osteomata require enucleation; 
malignant growths likewise, if seen 
in time. Unfortunately, their prog- 
ress is insidious and, as a rule, they 
are not recognized early enough to 
permit successful operative measures. 

ETHMOID CELLS. 

INFLAMMATORY DISOR- 
DERS. — The ethmoid cells may he 
the seat of acute and of chronic 
inflammation. 

Acute Inflammation; Acute Eth- 
moiditis. — The proximity of the an- 
terior ethmoidal cells to the frontal 
?nd maxillary sinus exposes them to 
involvement by contamination, while 
the posterior cells are exposed to it 
from the sphenoidal cells. Its con- 
n.ection with the nasal cavity exposes 
the ethmoidal sinus to the catarrhal 
■disorders and to occlusion, nasal 
growths, swellings, etc. Being itself, 
besides, liable to inflammatory disor- 
ders, this sinus is probably more fre- 
quently diseased than is generally 
supposed, and the underlying seat of 
many stubborn cases of chronic 
rhinitis. 

The symptoms of acute ethmoiditis 
are not always clearly defined. The 
pain is usually referred to the orow 
and behind the eyes, but sometimes 
only persistent headache is com- 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



155 



plained of. The discharge of the an- 
terior cells follows the same course 
as those of the antrum and frontal 
sinus, its elimination, anteriorly or 
posteriorly, if the nasal cavities are 
free, depending upon whether the 
head is bent forward or backward. 
Hence the fact that the nasopharynx 
often contains accumulated discharge 
in the morning after a night in the 
recumbent position. The acute form, 
which occurs as a complication of ar 
acute rhinitis or a temporary con- 
tamination from a neighboring in- 
flammatory process, disappears when 
the latter ceases, unless imperfect 
drainage prevents it. 

Chronic Inflammation or Chronic 
Ethmoiditis. — In this disorder the 
inflammatory process initiated by a 
similar process in the neighboring 
sinuses or the nose persists. In one 
form, the hyperplastic, the mucosa is 
swollen and gives rise to a watery 
discharge which is irritating to the 
nose, the aire, and upper lip. There 
is severe boring pain either in the 
supraorbital region, suggesting neu- 
ralgia, or at the root of the nose, 
radiating toward the temples. There 
may be a sensation of pressure in the 
eyes, muscse volitantes, and also an- 
osmia. The pharynx, larynx, Eustach- 
ian tubes, and middle ear may be 
involved in the inflammatory process. 
Asthma is sometimes witnessed in 
these cases. Acute exacerbations are 
common, a feature which leads to 
atrophy of the muciparous glands, 
atrophy, and even sclerosis. The se- 
cretion may then become scanty and 
form a tenacious mass which dries 
and forms foul-smelling crusts. 

The second form, suppurative eth- 
moiditis, dififers from the former, in 
that the discharge is purulent instead 



of merely watery. It may be caused 
by many morbid condition^ : adjoin- 
ing catarrhal disorders, imperfect 
drainage, syphilis, tuberculosis, ery- 
sipelas, influenza, and other infec- 
tions, fractures, operative trauma- 
tisms, etc. In most cases met with, 
however, obstruction of the outlet of 
the cells beneath the middle turbinate 
is a prominent cause. This may be 
due to the viscidity of the discharge, 
or, as is often the case, to mechanical 
obstruction in the middle turbinate 
or of the septum, either through 
osseous malformation or hypertro- 
phy of their mucosa. 

An important feature of this disor- 
der is that, owing to the thinness of 
the partition walls, these break down 
easily and necrose, giving rise to a 
foul discharge. In a large proportion 
of cases there is merely a copious 
purulent outflow, voided through the 
nose or nasopharynx, the latter of 
which it reaches from the superior or 
middle meatus. The pus may be 
sanious, contain bits of necrosed tis- 
sues and other detritus, and give off 
a more or less offensive odor. Pain 
is rarely observed in the chronic 
form, but a sensation of marked dry- 
ness may cause considerable discom- 
fort. 

If retention of the pus in the cells 
occurs through obstruction of their 
lumina, serious symptoms may be de- 
veloped, such as congestion, edema, 
bulging of and pressure in eyeballs, 
sometimes entailing diplopia and 
even blindness in neglected cases. 
Systemic disturbances, suggesting py- 
emia, may occur. Mental disorders 
and meningitis may also supervene if 
the pus invades the cranial cavity — a 
not uncommon complication, which 
often proves rapidly fatal. Cerebral 



156 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



abscess and thrombosis of the caver- 
nous sinus, from infection of the 
ethmoidal veins, may also occur. 
Fortunately, the most usual result is 
rupture, with formation of a fistula 
leading externally to and opening be- 
low the brow, over the inner angle of 
the eye. The pus is thus eliminated 
externally. 

The diagnosis of acute inflamma- 
tion of the ethmoidal cells should be 
based upon careful examination of the 
nasal cavities. The above-described 
symptoms are all observed in inflam- 
mation of other disorders. Sugges- 
tive in this connection, however, is 
redness of the lower edge of the mid- 
dle turbinate and extending beneath it. 
In the chronic form, a purulent dis- 
charge may be observed in this loca- 
tion coursing down along the external 
wall of the nose, and backward over 
the inclined surface of the inferior 
turbinate. 

Latent sinusitis of the ethmoidal 
sinus may be the underlying cause 
of certain reflex neuroses. A simple 
operation on the sinus in such cases 
frees the patient from his "neuras- 
thenia," "Meniere's disease," "hay 
fever," "nervous rhinorrhca" or other 
similar complaints. Menkes (Nederl. 
Tijdsch. V. Geneesk., Apr. 12, 1919). 

Treatment. — Acute inflammation 
of the ethmoidal cells is mainly per- 
petuated by obstruction of their out- 
let. The treatment recommended for 
acute inflammation of the frontal 
sinus in this section is also indicated 
here. In chronic inflammation the 
causative rhinitis, septal or turbinal 
malformation interfering with the 
drainage of the cells must be cor- 
rected. The measures indicated un- 
der Chronic Rhinitis (see page 72 
in the seventh volume) will prove 
very efficient. Local applications of 



a 20 per cent, solution of argyrol, 
after cleansing the nasal cavity, in- 
cluding the middle meatus, with 
warm saline solution is highly bene- 
ficial. This weak solution of argyrol 
may also be used with an atomizer 
provided with an upward tip, which 
may be passed under the middle tur- 
binate. If a stronger solution (50 
per cent.) is used, the applicator is 
preferable. Ichthiol and strong solu- 
tions of silver nitrate, which some- 
times are necessary, should only be 
used with the applicator. The possi- 
bility of involvement of the neighbor- 
ing sinuses should always be borne 
in mind and adequate treatment car- 
ried out if needed. 

The antrum often acts as a reser- 
voir for the pus originating in the 
ethmoidal or frontal cells, and hence 
efforts to cure an antrum abscess, 
without first curing the ethmoidal or 
frontal sinus abscess, prove futile, 
while, converse!}', the curing of the 
. latter will usually result in cure of 
the antrum disease without any at- 
tention being directed to the antrum 
itself. Todd (Jour. Minn. State Med. 
Assoc, and N. W. Lancet, Oct. 1, 
1911). 

When medication does not suffice, 
owing to obstruction ofifered by the 
middle turbinate to the drainage of 
the cells, the anterior portion, or in 
severe cases the whole turbinate, 
should be removed. By placing the 
diseased cells within reach of the 
remedies, and insuring efficient drain- 
age and ventilation, this procedure 
often suffices. When this does not 
suffice, the ethmoid cells must be 
opened by means of Hajek's curved 
hook, and enlarged with Griinwald's 
forceps. Saline solution irrigations 
mav then be used to wash out the 
cells, and a 10 per cent, argyrol spray 
to promote resolution, which often 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



157 



occurs. If it does not, and necrosed 
bone be found, Bryan's ethmoid cu- 
rette should be used to remove it 
while continuing the irrigations. 
Considerable care is necessary in this 
operative procedure to keep within 
the limits of the cells, as penetration 
of the cribriform plate above, or of 
the external cellular walls, may en- 
tail serious complications, and even 
death. 

The writer reports 2 fatal cases of 
suppurative ethmoiditis in children, 
and concludes that there is an in- 
creasing conviction that acute sup- 
purative ethmoiditis causing orbital 
and cerebral symptoms is not so 
rare a condition as has been thought, 
and that it is often rapidly fatal, 
especially in the young. The indi- 
cations for operation in acute eth- 
moiditis are sudden increase in tem- 
perature, delirium at night, tumor 
formation in the inner wall of the 
orbit, the slightest exophthalmos. 
Operation should not be delayed too 
long. As in appendicitis, early op- 
eration is a harmless procedure, late 
operation generally useless. 

When there is bilateral exophthal- 
mos, operation is generally useless, 
as the disease has probably extended 
through the cavernous and circular 
sinuses, causing a general toxemia 
and pyemia, or fatal brain lesion. 
Krauss (N. Y. Med. Jour., Apr. 24, 
1909). 

If it is the wish of the operator to 
clean out all the ethmoidal cells, the 
posterior half of the labyrinth is en- 
tered by piercing the attachment of 
the middle turbinate and by curetting 
still farther backward, using all the 
while the outer side of the middle 
turbinate as a guide. If the head of 
the patient is held level, the middle 
turbinate guides the curette back- 
ward into the posterior ethmoidal 
cell. Often the posterior half of the 
labyrinth is a large cavity, made up 
of only one or two cells. This por- 
tion of the labyrinth has been, as it 



were, exenterated by nature. When 
the curette brings up against the 
back wall of the labyrinth the re- 
maining part of the middle turbinate 
and the lower half of the superior 
turbinate are removed. Then the 
posterior part of the superior turbi- 
nate is taken away, flush with the 
front face of the sphenoidal sinus. 
The operator now recognizes the 
inner part of the front face of the 
sphenoidal sinus, which is free in the 
nasal cavity, and the outer part which 
has a common wall with the pos- 
terior ethmoidal cell. The posterior 
outer upper angle of the posterior 
ethmoidal cell is dangerous to cu- 
rette or to probe. It is of the utmost 
importance that the operator should 
be sure of his landmarks in this lo- 
cality. He orientates himself by find- 
ing the upper rim of the choana and 
then differentiating the free face of 
the sphenoidal sinus by proceeding 
upward from the rim of the choana 
close to the septum. Having made 
out the extent of the free face of the 
sinus, the width of the common wall 
between the sphenoidal sinus and the 
posterior ethmoidal cell is deter- 
mined. The dividing line between 
the two parts of the anterior face 
of the sphenoidal sinus is made by 
the obliquely vertical line, which is 
the attachment of the superior tur- 
binate. 

The usual mistake made by the 
operator is to get lost in the pos- 
terior ethmoidal cell — that is, he goes 
too high and too far outward, and 
considers the posterior wall of the 
posterior ethmoidal cell as the whole 
of the front face of the sphenoidal 
sinus. This mistake, if persisted in, 
will carry him into the brain. In- 
sufficient removal of the posterior 
part of the superior turbinate and 
allowing the head to become tipped 
upward, are the chief causes of this 
confusion. After the landmarks of 
the front face 'of the sphenoidal sinus 
have been cleared and recognized, the 
sinus is entered near the septum — if 
possilile, through the ostium — and 
the whole of the anterior wall re- 



158 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



moved. II. P. Mosher (Laryngo- 
scope, Sept., 1913). 

Non-operative treatment of infected 
sinuses, a suction apparatus being 
substituted, advised. The author has 
obtained entirely satisfactory results 
and has discarded oi)erative work, ex- 
cept on the antrum. Illustrative re- 
ports of successfully treated cases in- 
clude instances of severe acute fron- 
tal sinusitis; acute suppurative of the 
anterior ethmoid cells with orbital 
abscess; acute suppuration of the 
right frontal sinus; chronic suppura- 
tion of the frontal sinus, anterior 
ethmoid cells, and antrum; chronic 
suppuration of the left frontal sinus, 
and chronic suppuration of the pos- 
terior ethmoids and sphenoids. E. B. 
Gleason (Laryngoscope, 18, 1, 1918). 

TUMORS OF THE ETHMOIDAL 
CELLS. 
Benign Tumors. — Mucocele of the 
ethmoidal, irrespective of involve- 
ment of the other sinuses, is occa- 
sionally met with. It may occur as 
a result of chronic ethmoiditis, espe- 
cially when the ostium is occluded, or 
of blocking of some of the glandular 
acini. The tumor may fill the cell 
in which it is formed, break down 
the thin walls between the cells, or 
project out of the ostium and appear 
under the middle turbinate. Myxoma, 
osteoma, fibroma, and other benign 
growths may also occur in this loca- 
tion. All the growths develop in- 
sidiously, and cause no pain, until, in 
some instances, nerves are com- 
pressed, extended, or affected reflexly, 
or the neoplasm encroaches seri- 
ously upon neighboring structures 
and deforms them. In some cases 
other sinuses are penetrated by the 
growth which erodes the walls, 
separating them. 

Case of a lady who had been an- 
noyed for several months by a very 
profuse serous discharge from the 



right nostril when she stooped. This 
discharge was found to escape from 
a small opening in the top of carious 
bone in tlic wall of the bulla eth- 
moidalis. The dividing walls of the 
ethmoid cells had all been destroyed, 
making one cavity of the lateral mass 
of the ethmoid bone. This cavity 
was hned by a thin, white, glistening 
membrane, the typical cyst lining in 
appearnce. This membrane was cu- 
retted lightly, the cavity was packed 
for twenty-four hours to control 
hemorrhage, and then removed. A 
month later it was reported that the 
only change was that the discharge 
was now continuous, whereas for- 
merly it had taken place only upon 
stooping. Inspection of the nose 
showed a free opening into the cyst 
with fully two-thirds of the cavity 
covered with normal membrane. Six 
weeks later the patient reported en- 
tirely well. Thompson (Laryngo- 
scope, Mar., 1911). 

Malignant Tumors. — Sarcoma and 
epithelioma of the ethmoidal cells is 
occasionally observed as a primary 
process. In epithelioma the growth 
may be very insidious and be discov- 
ered only when stifficiently advanced 
to cause nasal obstruction, when ex- 
amination reveals its presence. A 
fetid discharge streaked with blood 
and detritus and enlargement of the 
glands behind the maxillary bone are 
suggestive. Sarcoma usually pro- 
gresses more rapidly, and is apt to be 
attended with free and, sometimes, 
dangerous hemorrhages. 

TREATMENT.— Surgical removal 
is alone of value. Malignant growths 
have often progressed sufficiently to 
involve many surrounding structures 
when first seen — a fact which greatly 
compromises the chances of recovery. 

Case in a man, aged 55 years, who 
was unable to breathe through the 
right nasal passage, but without any 
other symptom of distress. The pas- 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



159 



sage was found filled with cauliflower 
excrescences which bled at the slight- 
est contact with the probe. Poste- 
rior rhinoscopy revealed pretty much 
the same aspect, and digital explora- 
tion detected a soft vegetative mass 
covering the rhinopharynx, the right 
choana, and reaching from the roof 
to the soft palate, barely passing the 
middle line, and consequently leav- 
ing a free space upon the right side. 
On diaphanoscopy, the frontal maxil- 
lary sinuses became illuminated nor- 
mally. The mass was removed by 
external access with a good deal 
of hemorrhage, necessitating several 
tamponings. The middle and the su- 
perior turbinates were destroyed, the 
anterior ethmoidal cells resected to 
the cribriform plate of the ethmoid, 
and the septum was resected in its 
posterior portion. Every suspicious 
surface was thoroughly curetted, and 
hemorrhage arrested by tamponing 
the nasal fossse with iodoform gauze, 
and the skin wound united with su- 
tures. Recovery was good. Fifteen 
months later the patient still breathed 
freely, and his nasal fossa did not 
exhibit any trace of the growth. 
Audibert (Revue Hebd. de Laryn., 
d'Otol. et de Rhin., Feb. 24, 1912). 

SPHENOIDAL SINUS. 

INFLAMMATORY DISOR- 
DERS. — The sphenoidal cells may be 
the seat of acute and of chronic 
inflammation. 

Acute Inflammation. — Acute in- 
flammation of the sphenoidal sinus 
may occur as an extension of a 
similar process in the neighboring 
sinus, or the nasal and nasopharyn- 
geal cavities. It is identified with 
difficulty; the symptoms — a dull, 
deep-seated headache, referred by 
some patients to the occipital region, 
and by others to "somewhere behind 
the eyes" — constitute about all the 
subjective symptoms which suggest 
this disorder. Inspissated mucus, ac- 



cumulated in the postnasal space, to 
the exclusion of the anterior nasal 
cavities, and voided, as a rule, is an- 
other suggestive fact. In some cases 
these symptoms persist and consti- 
tute a mild "postnasal catarrh." In 
others, they disappear spontaneously. 

Chronic inflammation or empyema 
of the sphenoidal sinus may be due to 
infection by neighboring purulent 
process in the other sinuses or nasal 
cavities, or syphilis, tuberculosis, or 
fractures of the base involving the 
sphenoid. Besides the symptoms ob- 
served in the acute form, neuralgia 
throughout the distribution of the 
fifth pair may be experienced, tinni- 
tus and vertigo likewise. The dis- 
charge, instead of mucoid, is now 
mucopurulent and fetid, and tends to 
accumulate about the posterior end 
of the middle turbinate, and to pass 
down into the nasopharynx. When 
swallowed, especially if other sinuses 
are afifected, which is often the case, 
gastric disturbances and nausea may 
be caused. 

When obstruction of the sphenoidal 
orifice occurs, the symptoms in- 
crease greatly in severity, severe 
pain, insomnia, a febrile reaction oc- 
curring promptly. Extension of the 
inflammatory process to the brain is 
sometimes observed. As the disten- 
tion increases, ocular phenomena ap- 
pear, which may include congestion 
of the conjunctiva, swelling of the 
lids, and even amaurosis, owing to 
compression of the optic nerve. The 
swelling may block the posterior 
choane and cause violent aural symp- 
toms. Rupture may occur into the 
ethmoidal cells, the orbit, or the 
skull, and cause, in the latter case, 
rapidly fatal meningitis. 

The diagnosis of sphenoidal em- 



160 



SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 



pyema is based mainly upon the 
simultaneous presence of a persistent 
discharge into the posterior nares, 
traced above the vault area, and pain 
in the back of the head, after exclud- 
ing tlie other sinuses. 

The writer has devised an instru- 
ment which can be introduced into 
the pharynx by way of the mouth 
and which carries a miniature plate, 
so that this can be brought into con- 
tact with the wall of the sphenoid. 
By X-ray illumination through the 
frontal region of the cranium from 
above, an accurate picture can be ob- 
tained of the sphenoidal sinuses. The 
method is simple and yields valuable 
information regarding this region 
hitherto so difficult to photograph. 
Bela Freystadtl (Berl. khn. Woch., 
July 13, 1914). 

TREATMENT. — The treatment 
of intiammatory disorders is, in the 
main, similar to that of other sinuses 
reviewed. After applying a 10 per 
cent, solution of cocaine to the space 
between the middle turbinate and the 
septum, which will contract not only 
the tissues of these structures, but 
also those around the sphenoidal open- 
ing, a sphenoidal cannula is passed 
into the latter, and the cavity washed 
out with saline solution. Irrigation 
cannot be done sometimes without 
creating an opening in the most de- 
pendent portion of the sinus by 
means of a gouge passed along the 
surface of the middle turbinate, 
p)ointing the instrument upward and 
backward, under posterior rhinoscopy. 
Too big an opening by allowing the 
escape of a large quantity of pus to 
escape may cause syncope, hence a 
small opening is preferable at first. 
The curette is sometimes necessary, 
followed by saline solution irriga- 
tions and the local application of a 
10 per cent, solution of argyrol. 



Although it is not necessary to 
have the ostium in view in passing 
a sound, to the author's mind it is 
absolutely demanded when operative 
measures are about to be undertaken; 
the anatomic relations of the superior 
wall to the optic nerve and the pitui- 
tary body and the lateral walls to 
the sinus cavernosus and carotid ar- 
tery, to say nothing of the brain it- 
self, makes this region of operating 
one of extreme danger, unless the 
operator has perfect vision of the 
entire field. The lateral wall of the 
nose, as well as the septum, is co- 
cainized with a 20 per cent, solution, 
the posterior half of the middle 
turbinate is removed, the posterior 
ethmoid cells are broken through 
with Hajek's ethmoid hook, and the 
debris removed with a Griinwald- 
Hartmann conchotome or a similar 
instrument. The evulsor is then in- 
serted in the ostium and the opening 
enlarged by a few well-directed pulls; 
this is followed by the use of the 
bent forceps of Hajek and enough 
bone is removed as to insure a per- 
manent opening, which should reach 
as far as the floor of the nose. Com- 
plete healing usually takes place in 
from three to eight weeks, depend- 
ing on the degree of inflammation 
and the extent of the operative inter- 
ference. The advantages of this op- 
eration is that a full field is always 
in sight; the preliminary opening of 
the sphenoid from within outward 
thereby incurs no danger to the 
structures behind; and there is a 
permanent opening which lessens the 
danger of recurrence. Ross H. Skil- 
lern (Jour. Amer. Med. Assoc, Dec. 
19, 1908). 

The writer anesthetizes the nose 
with cocaine and epinephrin, and 
punctures the anterior wall of the 
sinus at its lower and internal por- 
tion. In the absence of any obstruc- 
tive deformity of the upper part of 
the septum nasi this can be readily 
accomplished in the vast majority of 
cases, and no removal of nasal tissue 
is necessary. This opening has the 



SKIN-GRAFTING (FREEMAN). 



161 



further advantage of being in the 
best position for drainage of the cav- 
ity. The operation is free alike from 
pain, hemorrhage, and danger. If the 
cavity is normal the wound will have 
closed in twenty-four hours. If the 
sinus is infected the operation affords 
the best possible opportunity for 
making an early and accurate diag- 
nosis and for the employment of 
suitable measures for local treatment, 
particularly lavage and drainage. C. 
P. Grayson (Penna. Med. Jour., Apr., 



1913). 

TUMORS OF THE SPHENOIDAL 
SINUS. 
Benign Tumors. — Myxomata and 
osteomata, occasionally found in this 
sinus, are harmful mainly because 
they tend early to produce obstruc- 
tion, and, therefore, bring- on em- 
pyema. As the tumor grows it brings 
on pressure symptoms, blindness or 
optic neuritis, when the optic nerve 
is compressed; exophthalmos of the 
eyeball, etc. 

Malignant Growths.— These pro- 
duce phenomena similar to those just 
described when they have progressed 
sufficiently to do so. A purulent san- 
guinolent discharge in the vault, 
traced upward to the sphenoidal 
opening, is about the only early sign 
availal)le. 

TREATMENT.— The location of 
the sphenoid renders operative re- 
moval impracticable, especially in 
view of the fact that the cases are 
usually far advanced when they 
reach the specialist. 

C. E. DE M. Sajous, 

Philadelphia. 

SKIN-GRAFTING. -When skin 
grafts are obtained from the patient 
himself, they are called autografts; 
when from another person, homo- 
grafts; and when from animals, coo- 



gra'ffs. The best results are derived 
from autografts. Homografts grow 
better than zoografts, but it must not 
be forgotten that they may cause dis- 
ease, especially syphilis, and that they 
may break down and disappear upon 
slight provocation. 

Reverdin's Method.— With fresh 
wounds or healthy granulating sur- 
faces little preparation is necessary. 
Freedom from suppuration would, of 
course, be desirable, but it is seldom 
attainable. When the granulations 
are not in good condition an effort 
should be made to render them firm, 
red and healthy by pressure, by re- 
peated cauterization with stick nitrate 
of silver, or by painting them occa- 
sionally with tincture of iodine. Leg 
ulcers may often be much improved 
by elevation of the extremity. Cal- 
lous ulcers should have radiating in- 
cisions made in their borders. Foul 
ulcers must receive preliminary anti- 
septic treatment, and all sloughs • 
should be cleared away before graft- 
ing is attempted. 

The grafts, which are best obtained 
from the arm or thigh, should be 
about the size of a grain of wheat. 
They are cut by elevating a portion 
of skin with mouse-toothed forceps 
and dividing it with scissors curved 
on the flat, removing the entire epi- 
thelium and a portion of the corium 
without disturln'ng the subcutaneous 
fat. The bits of cuticle adhere to the 
surface to be grafted, especially if 
gentle i)ressure with a pledget of 
gauze be employed. Nothing is 
gained by scraping or m any way 
wounding the granulations. The 
transplantations should be close to- 
gether, as the greatest size to which 
a graft can grow is perhaps that of 

a silver dime. Excellent grafts can 
11 



162 



SKIN-GRAFTING (FREEMAN). 



be cut with sharp-pointed scissors 
from the delicate pellicle of new skin 
which pushes out from the borders 
of a healing ulcer (Souchon). Imme- 
diately over the grafts may be placed 
strips of rubber protective, or a single 
layer of gauze, which may be pinned 
around a limb or fastened at the 
edges with collodion. Whether the 
external dressing is moist or dry is 
usuall}^ of little importance, but no 
antiseptic stronger than boric acid 
should be used. As there is gener- 
ally some suppuration, it is necessary 
to change the superficial portion of 
the dressing every twenty-four hours 
at least, leaving in place the rubber 
tissue, or the undermost layer of 
gauze, as the case may be. Gentle 
irrigation with a solution of salt or 
boric acid assists in maintaining 
cleanliness. The open method of 
dressing has recently come into use, 
and may often be employed to ad- 
vantage. In this the grafts are left 
entirely uncovered, being protected 
from injury by placing over them a 
"cage" made of wire gauze (a kitchen 
"strainer" for instance). The edges 
of the gauze are bound with adhesive 
plaster, a few strips of which may be 
utilized to hold the cage in position. 

Thiersch's Method. — There is no 
process of skin-grafting so simple, so 
reliable, and so generally applicable 
as this. It is of great value in the 
treatment of ulcers, burns, and de- 
fects following operations or injuries. 

The patient is anesthetized, and if 
granulations are present, it is best to 
scrape them away with a sharp spoon 
down to the comparatively firm tissue 
beneath, although this is not abso- 
lutely necessary. Oozing is checked 
by elevation and pressure, an Es- 
march strap being unnecessary. The 



grafts are cut with a razor from the 
anterior surface of the thigh or upper 
arm. An assistant makes the skin 
tense by means of a hand on either 
side of the limb, while the operator, 
standing with his back toward the 
patient's feet, cuts toward himself, 
with his left hand stretching the tis- 
sues in the direction of the knee. 
With a backward and forward saw- 
ing motion it is not difficult to obtain 
shavings of epidermis an inch or 
more wide and several inches in 
length, and as thin as paper: No 
objectionable scar results. The deli- 
cate strips of cuticle fold up on the 
blade of the razor, from which they 
may be spread directly upon the sur- 
face to be grafted, and so adjusted 
that they overlap each other and the 
edges of the skin, completely con- 
cealing the raw surface. Healing 
without suppuration is not uncom- 
mon. Over the transplanted cuticle 
are placed strips of rubber tissue, a 
single layer of gauze, or simply a 
wire cage as described in the Rever- 
din method. Davis uses a coarse- 
meshed net, such as is used for cur- 
tains, for "splinting" the grafts in 
position. The stiffening is washed 
out and the net is soaked in gutta- 
percha 30 parts, chloroform 150 parts, 
and is sterilized by keeping in a 
1 : 1000 solution of mercury bichloride. 
If a moist dressing is employed, it 
should consist of a thick pad of gauze 
saturated with normal salt solution 
and covered with cotton and oiled 
silk. This should be renewed often 
enough to keep it moist. A dry 
dressing answers equally well, ap- 
plied as in the treatment of ordinary 
wounds. The grafts do not become 
firmly fixed for nine or ten days, and 
it is well not to soak off the under- 



SKIN-GRAFTING (FREEMAN). 163 

most layer of gauze for about two is unfavorable for their existence. In 

weeks. five to seven days the granulations 

The Wolfe-Krause Method, — In are cut from above and the grafts 

this method grafts are employed exposed. 

which fill the entire defect, and which In caterpillar grafting, which really 
comprise the whole thickness of skin belongs to plastic surgery rather than 
without the subcutaneous tissues, to skin-grafting, a long, narrow, full- 
The fat may also be included if de- thickness flap (about 1 inch by 5 
sired, although the chance of success inches) is dissected up from the ad- 
is less (Hirschberg). In cutting the jacent integument with its base close 
skin at least one-third must be al- to the area to be grafted. The distal 
lowed for shrinkage. Sutures are extremity is then stitched close to the 
usually unnecessary and artificial heat base, thus humping the flap up in its 
is detrimental. center, much as a caterpillar crawls. 

Wolfe's original method has been After union of the tip has taken place 
modified and the technique improved in this position, the base is loosened 
by Krause, who employs spindle- and the flap straightened out upon 
shaped grafts, so that the wound the granulating surface. The oc- 
produced by their removal may be casions are not numerous, however, 
sutured immediately. The pieces of in which this "crawling" procedure 
skin, cut into smaller pieces, if desir- is preferable to free grafting, 
able, are accurately fitted into the Subcutaneous Skin-grafting. — Un- 
defect which is to be closed. The der ordinary circumstances skin- 
operation must be a "dry" one, and grafts cannot be used beneath the 
the raw surfaces of the skin should surface of the body owing to the 
be handled as little as possible. danger of infection. Rehn has dem- 

Skin-periosteum-bone grafts are onstrated, however, that this can be 

sometimes employed. They are cut done with more or less success by 

out bodily, from the tibial region, for shaving off the superficial portion of 

instance, without disturbing the con- the transplant, thus mechanically re- 

nections of the component parts to moving the bacteria. Grafts of this 

each other. character have been employed as a 

Two curious methods of skin-graft- substitute for lost tendons, to close 

ing introduced by MacLennan should the pylorus, etc., but it would seem 

be mentioned, although they are sel- that less complicated methods are 

dom employed. They are known as preferable, such as the use of fascia 

"tunnel grafting" and "caterpillar lata, 

grafting." Anomalies in Grafting. — Trans- 

In tunnel grafting small grafts are plantation of the mucous membrane 

slipped beneath the granulations into may be made. It may be shaved off 

little "tunnels" made for the purpose, as in skin-grafting, — for instance, 

where they are surrounded by ])l()od- from the lips, — or it may be stripped 

clot and protected from external in- off in its entirety. 

jury, which is supposed to facilitate More or less satisfactory results 

their growth under certain conditions, can be obtained by the use of shav- 

especially where the granular surface ings of callus from the palms of the 



164 SKIN-GRAFTING (FREEMAN). 

hands or soles of the feet, or from comes in time movable, but that pro- 
sections of corns. "Epithelial rods" duced from Reverdin grafts remains 
from warts have been successfully immovable, owing- to cicatricial tissue 
used, as have also flakes of old, dried between the individual bits of cuticle. 
epidermis from various parts of the Hairs may remain where transplanta- 
body; even "epithelial dust" scraped tions of the entire thickness of the 
from the surface of the skin will skin are made, but they are apt to 
often grow on a granulating wound, become deformed or fall out. But 
Deeper scrapings, drawing sufficient little postoperative contraction takes 
blood to form a paste which may be place in the Thiersch and Wolfe- 
spread upon a raw surface, are said Krause methods, but in the method 
to be quite satisfactory at times of Reverdin contraction is apt to be 
(Mangoldt). considerable. Exfoliation of epider- 

Grafting from dead bodies or from mis may occur in any form of graft- 
amputated limbs has frequently been ing, but this does not necessarily 
resorted to, but the chance of success mean that the grafts are dead. A 
is not great, and the danger of carry- remarkable phenomenon in connec- 
ing disease cannot be disregarded. tion with Thiersch grafting is the 

Sponge-grafting is now seldom em- readiness with which depressions fill 

ployed. Very thin slices of sponge up to a level with the surrounding 

are sterilized by boiling, and placed skin. 

upon the raw surface. The material In plastic work about the face it 

acts as a framework only for the should always be borne in mind that 

granulations, and is soon absorbed. flaps of skin from the vicinity, for 

The idea of grafting from animals instance from the neck, are preferable 
is attractive, but the results are too to free grafts, especially the thinner 
uncertain, and the method has largely ones, because their color and con- 
fallen into disuse. Skin has been sistency will conform more nearly to 
obtained from frogs (abdomen), that of their surroundings, thus ren- 
chickens (beneath the wings), pigs, dering them far less conspicuous, 
dogs, cats, rabbits, guinea-pigs. etc. COMPARISON OF METHODS. 
Cocks' wattles, sections of the testi- — The simplest is that of Reverdin, 
cles of rabbits, amniotic membrane, although the new skin is often little 
and the lining membrane of eggs better than scar-tissue. It should be 
have also been employed. reserved for cases where the rapid 

HISTOLOGY AND PATHOL- closure of a granulating surface is 
OGY. — The existence of epithelial desired without reference to anything 
grafts may be said to be, for a time, else. Thiersch grafting has a wider 
parasitic. In the course of about range of applicability than anv other 
eighteen hours vascular connections method, and its results are uniformly 
begin to form, firm adherence taking good, both functionally and cosmetic- 
place by the tenth day. Successful ally ; but it must give way to the 
grafts soon become pinkish in color. Wolfe-Krause process when thicker 
New skin arising from large grafts, skin is desired, which more closely 
which cover the entire raw surface resembles the surrounding integu- 
(Thiersch and Wolfe grafts), be- ment. It may sometimes be expedi- 



SKIN, SURGICAL DISEASES OF. 



165 



ent to graft from dead bodies or from 
amputated limbs; and occasionally 
use may be found for "epidermal 
scrapings," or for epidermis obtained 
from warts, corns, callosities, blisters, 
etc., but one must not expect the 
results to be brilliant. 

The skin of animals does not com- 
pare in vitality with that taken from 
a patient's own body, or even from 
some other person. It is seldom 
necessary to transplant from mucous 
membrane, as ordinary Thiersch 
grafting answers the same purpose in 
nearly all cases. 

Leonard Freeman, 

Denver. 

SKIN, SURGICAL DISEASES 

OF.— SEBACEOUS CYSTS, or WENS. 

— A wen (steatoma) is a cystic tumor 
varying in size from a millet-seed to an 
orange, formed by the retention of secre- 
tion in a sebaceous gland, and situated 
in the skin or subcutaneous structures. 
Wens occur most frequently on the scalp, 
face, back, and scrotum, and may be 
single or multiple. The contents of these 
tumors are milky or cheesy in character, 
but if the tumor be injured, inflammation 
and ulceration may follow, or in the aged 
the tumor may acquire a malignant char- 
acter, degenerating into epithelioma. 

Treatment. — A cure will be effected by 
making an incision in the skin down to 
the cyst and carefully dissecting it out. 
Incision and mere evacuation of the con- 
tents are always followed by a return of 
the tumor. 

FURUNCLE. — Furuncle (furunculus ; 
boil) is a local inflammatory affection of 
the skin, commonly involving a cutane- 
ous gland or hair-follicle. They may oc 
single or multiple, and may appear in 
"crops." 

The diagnosis of the affection is usu- 
ally quite easy. It may sometimes be 
confounded with carbuncle. General ap- 
pearance, single opening, and circum- 
scribed character usually distinguish the 
boil. 



Etiology. — Improper diet and hygiene, 
nervous depression, overwork, too free 
indulgence in greasy foods and gravies, 
and irregular action of the bowels, local 
irritation, friction, and prolonged poultic- 
ing predispose to this affection. The en- 
trance of pus-cocci into the skin is the 
essential or exciting cause of this dis- 
order. Single boils are usually the result 
of local irritation; their appearance in 
successive crops (furunculosis) is usually 
an indication of impaired health. 

Treatment. — Removal of the cause and 
regulation of the diet claim first attention. 
Open-air exercise and tonics are useful in 
debilitated sul)jects. Strong ammonia, 
caustic potash, acid mercury nitrate, and 
other forms of caustic have been used to 
abort in the early stage. Yeast, nuclein, 
quinine, and mineral acids have been 
given to prevent recurrence. Arsenic, 
with or without iron, is sometimes bene- 
ficial. Sodium sulphite or thiosulphate 
(IS to 30 grains — 1 to 2 Gm.— every three 
hours), calx sulphurata (% grain — 0.008 
Gm. — every two or three hours), or sul- 
phur may be given internally. A solution 
of boric acid or of sublimate, a 10 per 
cent, salicylic acid ointment, or a mix- 
ture of equal parts of ichthyol and col- 
lodion may be applied locally. White has 
used full doses of mercury bichloride in- 
ternallj' to prevent recurrence. 

Hypodermic antiseptic injections into 
the very base of a boil or carbuncle, early 
in its history, are practically an unfailing 
means for aborting an attack. 

Heat is directly injurious to the mi- 
crobes of furunculosis; active hyperemia 
is induced, and the skin sterilized; the 
profuse sweating induced prevents rapid 
increase of temperature in the deeper 
tissues. The hot air is first applied 
around the circumference of the affected 
part, and then to the boil itself. Two or 
three applications are given on the first 
day, and one daily afterward. Temper- 
ature of air, 250° F. (120° C.). 

CARBUNCLE.— Definition.— Carbuncle 

(carbunculus; it is erroneously called 
benignant anthrax, or anthrax") is a hard, 
circumscribed, deep-seated, painful inflam- 
mation of the subcutaneous tissue, ac- 
companied by chill, fever, and constitu- 
tional disturbance, and attended almost 



166 



SKIN, SURGICAL DISEASES OF. 



always with circumscribed suppuration 
and the formation of a slough. 

Symptoms. — The local symptoms are 
heat and aching, with throbbing and great 
tenderness, which are often followed by 
pain and redness along the lymphatics of 
the part and pain and swelling in the 
nearest lymphatic glands. There is at 
first a chill, followed by a febrile move- 
ment, which is generally well marked, 
and often very severe. The constitu- 
tional symptoms resemble those of ery- 
sipelas very closelj^ and may be as se- 
vere as those of the severest forms of 
that disease, and the consequences may 
be fully as grave and fatal. 

Diagnosis, — The size of the inflamed 
area, flatness- of surface, multiple open- 
ings or points of suppuration and exten- 
sive slough differentiate carbuncle from 
furuncle. Carbuncle is single, furuncle 
generally multiple. 

Etiology. — A lowered vitality from any 
cause predisposes to this affection. It is 
especially common in diabetes. Microbic 
infection is the exciting cause. 

Prognosis. — Carbuncle is especially dan- 
gerous when located on the scalp, abdo- 
men, and upper lip; in these locations it 
is apt to occur in young people, and 
usually runs an acute course and, as a rule, 
is fatal from pj-emia. The prognosis is 
grave when extensive and attacking the 
elderly, especially if complicated with 
Bright's disease or diabetes. The prog- 
nosis should always be guarded, even in 
the most hopeful cases. Death is not in- 
frequent in the old and debilitated. 

Treatment. — General tonics, like quinine 
and iron, with large amounts of nourish- 
ing food, are indicated. Opium or other 
anodynes may be required to relieve pain 
and procure rest. Stimulants should be 
given only when required. 

Reynolds advises dilute sulphuric acid 
in 20- to 30- minim (1.3 to 2 c.c.) doses in 
2 ounces (60 c.c.) of water every four 
hours (small doses are useless), with 5 
per cent, carbolized petrolatum locally. 

In the early stage 10 to 20 minims 
(0.6 to 1.3 c.c.) of a 5 or 10 per cent, 
solution of phenol in glycerin may be in- 
jected into the central portion of the mass 
with the view of aborting the mischief. 
If seen later, firm compression by straps 



hi adhesive plaster applied concentrically 
may be made, leaving the central orifice 
free for the discharge of sloughs and ap- 
plying an antiseptic dressing over the 
straps. 

Another plan, applicable in the early 
or late stage as well: Place patient un- 
der an anesthetic; freeze the parts to 
make them friable; make one long in- 
cision or several crucial incisions through 
the mass; remove all sloughs and decay- 
ing tissue with a sharp curette; disinfect, 
drain, and suture, as in an incised wound. 

Another method of treatment is the 
application of warm, moist, antiseptic 
dressings, covered with thin rubber cloth 
or oiled silk, removing sloughs as soon 
as loosened, and using iodoform, aristol, 
europhen, or similar antiseptic powder 
freely. The use of poultices is harmful 
and should be avoided. 

The use of autogenous vaccine, once a 
week in dose of 100 to 200 million dead 
cocci was effectual. Bier's passive hyper- 
emia by means of band around lower part 
of the neck was used with success in 
carbuncles of the face and high up on 
neck. Mild constriction was sufficient for 
twenty to twenty-two hours daily unless 
edema appeared. 

Ichthyol is practically a specific in the 
treatment of carbuncles, applied pure, so 
as to cover the entire swelling, except the 
apex. The apex on which the ichthyol 
is absent is covered with a piece of cloth 
greased with tallow. The application is 
renewed once a day. After three appli- 
cations the surface should be washed 
thoroughly so as to remove the varnish- 
like coating which the ichthyol forms on 
drj'ing, and a new application is to be 
made. 

Personal experience in the local treat- 
ment of carbuncle with liquid air has 
shown A. Campbell White that this is by 
far the best form of treatment. It is less 
painful to the patient than any other form 
of treatment. Only one application is 
necessary. In the treatment by liquid 
air the spray is used, first projecting it 
into the openings and using the air quite 
freely; then quite thoroughly freezing the 
external surface, which must be well 
cleansed of discharge resulting from 
sending air inside the carbuncle before 



SKIN, SURGICAL DISEASES OF. 



167 



freezing. After freezing the carbuncle 
should be dressed with a dry absorbent 
dressing. The reaction from freezing 
takes place in about twenty minutes, and 
it is to this extreme hyperemia that the 
success of liquid air in the treat- 
ment of this affection is attributed 
more particularly. 

KERATOSIS SENILIS.— This affec- 
tion is a cornification of the skin of old 
people, general or partial, circumscribed 
or diffuse, and often limited to the face 
and the dorsal surfaces of the hands and 
feet, or sometimes the forearm and chest. 
The lesions consist of light- or dark- 
yellow, brownish points, dry scaling and 
horny, or scaling and greasy, aggregated 
masses of an irregular circular or oval 
outline. The surface of these masses is 
insensitive, and may project about an 
eighth of an inch above the surface. 
These masses may be readily picked off, 
leaving a small, superficial, smooth, ex- 
coriated surface or one covered with 
minute conical elevations (enlarged se- 
baceous glands). This affection rarely 
appears before the fiftieth year, and may 
not claim attention until fifteen or 
twenty years later. 

Prognosis. — The prognosis is favorable 
if the proper treatment is promptly ap- 
plied. When left alone the pigmented 
masses are prone to epitheliomatous de- 
generation, and may become foci for 
carcinoma of the face, in which case the 
dry scales are displaced by a scab, the 
tissues become hard, and growth is more 
rapid. 

Treatment. — In the early stage, in- 
unctions with petrolatum or olive oil 
and the subsequent use of soap and warm 
water will remove the trouble. When the 
masses are firmer, ointments should be 
applied at night, and soft soap or sapo 
viridis in the morning, removing the 
soap by carefully washing with clean, 
warm water; applications of diachylon 
ointment will heal any excoriations that 
may have been produced. When marked 
projection of the mass is present, the 
thorough use of the curette, or nitric 
acid on a pointed stick, well worked into 
the parts, will remove the affected tis- 
sues. If epitheliomatous change is sus- 
pected, prompt excision is indicated. 



CLAVUS (CORN).— Clavus is an hy- 
perplasia of the corneous or horny layer 
of the epidermis, in which there is an in- 
growth as well as an outgrowth of horny 
substance, forming circumscribed epi- 
dermal thickenings, chiefly about the toes. 
Corns may be hard or soft, the latter be- 
ing situated between the toes, where they 
become softened by maceration. Both 
forms are caused by intermittent pressure 
and friction. Pressure produces pain by 
driving the conical mass of hardened epi- 
thelium down upon the sensitive coriuni; 
constant irritation may produce inflam- 
mation and suppuration. 

Treatment.— The use of well-fitting, 
comfortable shoes made on properly 
shaped lasts is the first indication. Tem- 
porary relief from hard corns may be 
obtained by the use of felt rings which 
are applied over the corns, allowing the 
latter to project through the opening. 
Prolonged soaking in a warm solution of 
sodium carbonate will soften the corn, 
when it may be removed by gentle scrap- 
ing with a sharp knife; the tender sur- 
face left may be protected by covering it 
with a plaster-of salicylic acid or of sali- 
cylic acid with cannabis indica. Another 
method is that of hardening the surface 
of the corn by applications of the tinc- 
ture of iodine or silver nitrate at night, 
removing the hardened tissue on the fol- 
lowing morning. A third method is the 
use of the salicylic-collodion mixture: 
Salicylic acid, 30 grains (2 Gni.); tincture 
of iodine, 10 minims (0.6 c.c); extract of 
cannabis indica, 10 grains (0.6 Gm.); col- 
lodion, 4 drams (15 c.c); this to be 
painted on the corn night and morning 
for several days and then removed with 
the corn, by soaking in hot water. Soft 
corns are best treated by gentle scraping 
to remove the softened epithelium, the 
surface being then protected by a pad of 
natural wool (as it is clipped from the 
sheep), or of absorbent cotton, having 
previously dusted the surface with a 
powder composed of equal parts of zinc 
oxide and boric acid. When corns be- 
come inflamed, rest and warm, moist, 
antiseptic dressings meet the indications. 
If pus has formed it must be afforded 
an exit and the wound treated with anti- 
septics, iodoform, anatol or europhen. 



168 



SKIN, SURGICAL DISEASES OF. 



Corns should never be cut too closely, as 
erysipelas and gangrene may follow, espe- 
cially in the aged. 

VERRUCA.— Verrucse (condylomata; 
warts) are circumscribed papillary ex- 
crescences on the skin, variable in color, 
smooth at the summit, or studded with 
moniliform elevations or with clusters 
of minute, pointed, horny filaments. 
They may be single or multiple, hard or 
soft, rounded, flattened or acuminate. 
They may rapidly attain their full size, 
may last indefinitely (/'. pcrstans), or 
spontaneously disappear, at any stage, 
and are not contagious. If picked or 
wounded, warts bleed freely, being often 
very vascular. The etiology of warts is 
obscure. 

Treatment. — The milder applications 
consist of the juice of the milk-weed (As- 
clcpias coniuti sen Syriaca), the tincture 
of iodine, the solution of iron perchloride, 
moistened powder of ammonium chloride; 
stronger applications are sublimate col- 
lodion (30 grains to the fluidram), glacial 
acetic acid (best of acids, as it leaves no 
scar), chromic acid and fuming nitric 
(nitroso-nitric) acid. Excision (warts on 
the face should never be cauterized, but 
excised) or curettage if the warts be 
soft, is the quickest method of removal; 
the hypodermic injection of cocaine will 
lessen or prevent the pain, and the ap- 
plication of fuming nitric acid to the 
stump or base will restrain the hemor- 
rhage and prevent return. A 10 per cent. 
salicylic acid or resorcin ointment is slow 
but effectual. Electrolysis is efficient but 
painful, for large warts. Ethyl chloride 
spray, liquid air, and carbon dioxide 
snow are efiicient. Quicklime rubbed on 
the hands and washed off in an hour is 
effective when warts are numerous; this 
should be done twice daily and con- 
tinued for a fortnight. Intravenous in- 
jections of salvarsan and neosalvarsan 
have been used successfully when warts 
were numerous. 

The internal use of >< pint (250 c.c.) of 
lime-water daily for a week (Kennard) and 
1 dram (4 Gm.) doses of Epsom salt 
thrice daily (Ridley) have given satisfac- 
tory results. 

Instead of cutting or the use of caustics, 
Purdon uses an India-rubber finger-stall. 



if the warts are on the fingers, or an 
India-rubber bandage, if they are on the 
hands. The ruljl)er exerts gentle pres- 
sure, while the wart is kept moist and 
macerated from retained perspiration. 

Venereal warts may be washed well 
with bichloride or other antiseptic solu- 
tion, and then dusted with iodoform, 
calomel, aristol, or europhen. 

HYPERTROPHIED SCARS.— When a 
wound is completely healed, a cicatrix or 
scar occupies its place. Normally, two 
things are observed in a scar: its contrac- 
tion and the gradual perfecting of its 
tissues. The principal changes by' which 
the latter is accomplished are the re- 
moval of all the rudimental textures; the 
formatiori of elastic tissue; the improve- 
ment of fibrous or fibrocellular tissue of 
the new cuticle till they are almost, but 
not exactly, like those of natural forma- 
tion; and the gradual loosening of the 
scar, so that it may move easily upon 
the subjacent tissues. 

Treatment. — Hypertrnphied scars may 
be treated by multiple incisions and 
thiosinamine. Tubb}- uses a fine and 
strong-backed tenotomy knife and makes 
a large number of incisions in the scar 
tissue, transversely to the long axis of 
the scar, not more than Yio inch apart, 
and extending both into the subcutaneous 
fat and for about l^ inch into the adja- 
cent healthy skin. Hemorrhage is stopped 
by pressure alone, and then a solution 
of thiosinamine is thoroughly rubbed in. 
P^'rom 15 to 20 minims (1 to 1.3 c.c.) of 
the solution may be injected at one time 
in an adult. After injection the part is 
splinted in extreme extension. 

Fibrolysin plaster applied to the scar 
and left for fourteen days, gave excellent 
results. 

Excision of the scar and repair by 
plastic operation is applicable in some 
cases. See also page 176. 

KELOID.— Keloid (cheloid; kelis; Ali- 
bert's keloid; spurious keloid) is a new 
growth of connective-tissue formation 
having its seat or origin in scar tissue 
and resulting in the formation of single 
or multiple tumors. 

Symptoms. — It first appears as a pale- 
red nodule which slowly increases in size, 
assuming a more or less oval form, with 



SKIN, SURGICAL DISEASES OF. 



169 



irregular, well-defined, radiating projec- 
tions. From its resemblance to a crab 
it derives its name. It may more rarely 
assume a linear form. The new growth 
is smooth, firm, elastic, pinkish, elevated, 
generally devoid of hair, usually painless, 
but sometimes tender when touched or 
subjected to pressure; and is occasionally 
the seat of the most intolerable itching, 
which no external application seems to 
relieve. The favorite location of this 
growth is over the sternum, but it may 
be situated on the mammae, the neck, 
arms, and ears. In rare instances the 
growth may become inflamed and assume 
for a while the appearance of malignancy, 
which appearance disappears usually with 
the spontaneous decline of the inflam- 
matory action. The development of the 
growth may be slow or rapid, until a 
stationary period is reached, which varies 
in duration. Spontaneous disappearance 
of the growth not infrequently occurs. In 
some cases the growth becomes painful, 
in others a pigmentary deposit is noticed. 
This condition was first described by 
Alibert, and is known as spurious keloid 
to distinguish it from true keloid, which 
does not attack scars (Erichsen). 

Diagnosis. — AUbert's keloid is dilifer- 
entiated from a simple cicatrix by its 
diiiference in consistence, outline, color, 
and elevation, and by its increase in size. 
Its points of difference from hyper- 
trophicd scars have been mentioned. 

Etiology and Pathology. — These new 
growths have their origin at the seat of 
some injury (sometimes very slight) to 
the skin, as the cicatrices of burns, flog- 
gings, cuts, or in the lobes of the ears 
when they have been pierced for the 
accommodation of earrings. They are 
most frequent in middle life and in the 
colored race. The growth consists of 
dense fibrous tissue, which involves the 
corium and extends in the direction of 
the connective tissue about the blood- 
vessels. 

Prognosis. — The prognosis is not gen- 
erally very favorable, although the growths 
may sometimes disappear spontaneously. 
The stationary period may extend over 
years or during life. Occasionally, after 
a stationary period of variable duration, 
an increase in size takes place. 



Treatment. — The treatment of these 
new growths is not very satisfactory. 
The application of anodyne liniments or 
hypodermic injections of morphine will 
generally relieve pain when present. The 
administration of large doses of liquor 
potassae will often relieve the pruritus. 
Removal by knife or caustics should not 
be attempted while the growth is increas- 
ing. Fused caustic potash is recom- 
mended as best, if any caustic is used. 
Multiple electrolytic puncture and re- 
peated scarification, making numerous 
parallel linear cuts crossed at various 
angles by other parallel linear cuts, have 
been suggested with the idea of replacing 
the diseased scar by a healthy one. 

Sodium salicylate taken internally (20 
to 30 grains— 1.3 to 2 Gm. — three or four 
times daily) has a marked effect in the 
resolution and absorption of keloid. In- 
jections of fibrolysin (35 minims — 2.3 c.c.) 
made daily or even once a week has 
caused the disappearance of keloid. 

Radium has proven highly effectual both 
for keloids, excessive scarring, and deep 
fibrous adhesions. All cases of keloid re- 
ported on by F. C. Harrison (1918) 
showed disappearance or marked improve- 
ment under radium. Weil exposed keloid 
to very hard X-rays. Lesieur reported 
satisfactory results in 100 cases from in- 
jections of creosote in sterile olive oil, 
1:15; 2 drops to 80 minims (5 c.c.) are 
injected under the keloid at each sitting. 

MALIGNANT DEGENERATION OF 
SCARS. — The cicatrix of a burn or other 
extensive scar may undergo malignant 
degeneration many years after its forma- 
tion. Erichsen removed a large cancroid 
growth from a cicatrix of a burn, on the 
forearm of a woman, seventy years after 
the receipt of the injury, which happened 
in childhood. 

BURNS. 

DEFINITION.— A burn is a high 
grade of acute inflammation, following 
the direct or indirect application of dry 
or moist heat to a portion of the cu- 
taneous or mucous surfaces. 

VARIETIES.— For ease of comprehen- 
sion burns have been separated into 
grades according to their severity. 

A temperature, slightly increased above 
the normal (as, for instance, 100° F. — 



170 



SKIN, SURGICAL DISEASES OF. 



37.8° C), produces only a slight hyper- 
emia (first degree: dermatitis ambus- 
tionis erythematosa), which may dis- 
appear shortly after breaking the contact, 
while a rise of 150° F. (65.6° C.) will 
cause some appearance of vesicles and 
bull?e (second degree: dermatitis am- 
bustionis vesiculosa et bullosa) and de- 
struction of the epidermis, the effect of 
which is not relieved for days after the 
removal of the burning substance, and 
yet, on the other hand, heat at the boil- 
ing point of water (212° F.— 100° C.) 
may cause a complete carbonization of 
the part, resulting in the formation of 
eschars varying in color from a yellow 
up to a dark brown or black or, in other 
words, the production of gangrene (third 
degree: dermatitis ambustionis escharot- 
ica seu gangrenosa). 

SYMPTOMS.— The effects of a burn 
upon the body structure are both local 
and constitutional. The former often 
results in great disfiguration or destruc- 
tion of tissue, while the latter depresses 
the vital forces or terminates in death. 

Local Effects. — In burns of the first 
degree the appearances produced are su- 
perficial. There will be observed a dis- 
tinct hyperemia with redness of varying 
intensity from the slightest blush up to a 
pinkish red or brownish red. This may 
or may not be entirely effaced by pres- 
sure. This type of burn is produced by 
indirect contact with the flame of a 
lighted match, proximity to a heated 
metal, escaping steam, and the actinic 
rays of the sun. With or without treat- 
ment the effect of burning to this extent 
maj' disappear shorlj' after removing the 
exciting cause. 

In burns of the second degree the in- 
flammation, while yet superficial, may 
still occupy the entire epidermis. In 
some cases the upper layers alone of the 
cuticle may be destroyed, while vesicles 
or bullae may be observed over the af- 
fected surface. In still other cases the 
corium is stripped entirely of its epi- 
dermal covering or particles of the mem- 
brane may be rolled into whitish masses 
over its exposed surface. These vesicles 
or bullae may be produced directly by the 
contact of the heated article or indirectly 
by the consequent inflammation. They 



may retain their contents or, owing to 
the increased flow of serum, their walls, 
becoming thin and losing their elasticity, 
rupture, thus allowing the escape of a 
continual discharge over the denuded sur- 
face. The true skin, which is exposed 
either entirely or at points, shows a 
highly reddened surface, over which this 
continual exudation may be observed. 
In this type of condition actual contact 
with the heated substance takes place 
either in shorter or longer durations. 
Such articles as heated iron, transient or 
lengthened action of flames, aiid boiling 
liquids may be the exciting agent. The 
effects of this form of burn do not al- 
ways show to what extent they have 
progressed immediately upon the removal 
of the cause, because of the systemic con- 
ditions which may be induced. Pain is 
always present to a minor or major 
degree. 

Resolution takes place through coagu- 
lation of the serous discharge, which 
occupies the involved area as a fibro- 
albuminous covering beneath which the 
new skin is allowed to form. 

In the burns of the third degree the 
inflammation or destruction may be su- 
perficial, extending over considerable area, 
or deep, affecting the subcutaneoos tis- 
sues, muscles, and even bones. 

Resolution takes place in the uncovered 
variet}' in the same manner as described 
under the foregoing degree, while in the 
covered variety granulations spring up 
beneath the charred remains which, after 
a time, desiccate and fall off, exposing a 
similar surface to that of the second 
degree. 

In the deeper form of burn the extent 
of surface involved may be small or 
large, but may dip down to varying 
depths. The amount of charring will usu- 
ally be very great and will lie about in 
masses over the burned surface, thus 
preventing a view of the destruction be- 
neath. Resolution even in the milder 
cases is slow, and before such happens 
surgical interference may be demanded. 
The cause which brings about this form 
of burning is usually dry heat (flames or 
contact with electric wires); it entails 
much greater destruction than will moist 
heat. The effect upon the system is 



SKIN, SURGICAL DISEASES OF. 



171 



alarming, and shock may carry off the 
person before relief can even be attempted. 

Electric and X-ray Burns. — Burns from 
electricity may be observed in all the 
varieties mentioned above. They may 
follow^ direct or indirect contact. Exam- 
ples of direct contact are observed after 
handling live (charged) wires, and may 
be found to destroy all parts with which 
it comes into touch, or life even may be 
the forfeit. Such burns resemble moist 
gangrene or severe frost-bite. The pain 
is often very severe and the healing pro- 
cess is much slower than in the case of 
ordinary burns. 

A most recent form of burning of the 
skin from the indirect contact of elec- 
tricity is by the X-ray apparatus. Close 
proximity to the ray by either covered or 
uncovered parts result either in a super- 
ficial or deep inflammation of the skin. It 
may be observed a few hours after ex- 
posure to the rays or may be delayed for 
several weeks. This form of burning at- 
tacks the skin alone in some instances, 
while in others the deeper structures, as 
the muscles, tendons, nerves, and bones 
(periostitis and ostitis resulting) are in- 
volved. The effects may remain for days, 
weeks, or even months after the applica- 
tion. The X-ray burns are supposed by 
some to be produced by the action of the 
ray or by particles of aluminium or 
platinum reaching and being deposited in 
the tissues by others, and by others to be 
the result of an interference with the 
nutrition of the part by the induced 
static charges. 

The patient may be absolutely pro- 
tected from the harmful effects of this 
static charge by the interposition between 
the tube and the patient of a grounded 
sheet of conducting material that is 
readily penetrable by the X-ray, a thin 
sheet of aluminium or gold-leaf spread 
upon cardboard making an effectual protec- 
tive shield. 

Burns of Mucous Surfaces. — The mu- 
cous surfaces may be affected by the 
inhalation of flames, vapors (volatile or 
boiling acids), boiling liquids (water, 
slacked lime), and by certain substances 
acting directly, such as ammonia and 
sulphuric and hydrochloric acids. The 
mouth, pharynx, larynx, bronchi, and 



the esophagus, as well as the stomach, 
share in the attack. The eye often, from 
its exposed position, is the seat of burn. 
Conjunctivitis often results from irritants 
coming into direct contact with the eye, 
and if the exciting agent is not soon re- 
moved great destruction of substance or 
sight may be the result. 

Constitutional Effects.— The effects of 
burns of the first degree upon the system 
are generally slight and are limited to 
pain which disappears shortly after the 
removal of the exciting agent, but often 
may last for several hours. 

In burns of the second degree the pain 
accompanies the phenomena not alone for 
hours and days, but often for weeks and 
even months. The shock may be of a 
transient character or of an alarming in- 
tensity. It may be encountered at the 
time of accident or be delayed for peri- 
ods varying from hours to days there- 
after. When small areas are involved, 
the depression may soon be relieved, but 
when one-fourth or one-third of the 
body is attacked death may intervene. 

Burns of the third degree may be so 
severe that death intervenes before pain 
has time to appear. Shock at this stage 
is therefore observed early and of the 
worst character. Early mortality is gen- 
erally due to the shock, while late mor- 
tality usually occurs during the stage of 
suppuration. Vomiting is often observed 
in both the second and third degrees. 

Children suffer more from burns than 
do adults, and women more severely than 
men. The temperature is not affected by 
burns of the first degree, but is a marked 
symptom in those of the second and third. 
At the time of the accident it may de- 
cline from 1 to 3 degrees below the 
normal— to 97° F. (36.1° C.) or even 95° 
F. (34.9° C.) and remain at that point 
until reaction begins, which is in about 
thirty-six or forty-eight hours, when it 
rises during the next twelve to eighteen 
hours to 104° F. (40° C.) or 106° F. 
(41.1° C.) or more, at which point it re- 
mains for a period of eight to ten days 
(possibly rising and lowering at irregular 
intervals), when granulations, now in fair 
formation, act as a retarding agent. 

Vannini reported cases of six burns of 
varying degrees of severity, in all of 



172 



SKIN, SURGICAL DISEASES OF. 



which glycosuria was present. The gly- 
cosuria was, as a rule, transitory, and 
was, in all probability, toxic in its origin, 
and connected with hyperglycemia. When 
sugar is present after burns, the diet of 
the patient should be modified. 

COMPLICATIONS.— The after-effects 

of burns may be concentrated upon the 
viscera (neural, thoracic, and ventral cavi- 
ties) or directly upon the part affected 
(cicatrices, contractions, and fractures of 
bone). Burns of the first degree remain 
uncomplicated, while those of the second 
and third present many variations. The 
meninges (arachnitis following burns of 
the head), as well as the brain proper, 
may become congested or even highly 
inflamed, the sufferer presenting all the 
symptoms of restlessness and delirium 
ending either in convulsions or coma. 
Tetanus is an early complication ob- 
served. Bronchitis and pneumonia often 
result either from inhalations or indi- 
rectly from surface burns. Congestion in 
the kidney has been noted, with resulting 
albuminuria or hemoglobinuria, while in 
many cases the urine becomes exceedingly 
scanty. Autopsies have shown rupture of 
the diaphragm and stomach, accompanied 
by contraction of the bladder. Amyloid 
degeneration in the viscera has been noted 
after prolonged suppuration. Inflamma- 
tion of the gastrointestinal tract with 
the formation of an ulcer (usually one, 
but more rarely several) of the duodenum 
(at its pyloric end) frequently occurs. 
This ulceration may begin early (four or 
five days) or it may be delayed for 
weeks, although without the appearance 
of rectal hemorrhage or perforation, with 
consequent peritonitis, we have no means 
of determining its presence. At times 
this inflammation extends to the colon 
and causes diarrhea. Burns affecting 
either the chest or abdomen are the in- 
ducing cause, although severe burns at 
other points may produce them. Sep- 
ticemia, pj^emia, or erysipelas (the strep- 
tococci being found after death in the 
blood) may be the fatal ending. 

The theories of the causes of death from 
burns may be divided into four classes: 

(1) death from shock or extreme pain; 

(2) embolism, thrombosis, and destruc- 
tion of the blood-elements; (3) pyemic 



infection through the burned surface; 
(4) poisons formed by the action of heat 
on the tissues, or autointoxication from 
deficient excretion by the skin. By ex- 
perimenting upon dogs and rabbits it is 
personally claimed that the intoxication 
theory is the correct one. 

The attempt of nature to restore a cov- 
ering for these denuded tissues often re- 
sults unwisely. Vicious scars, adhesions 
of contiguous parts (causing webbed fin- 
gers, the arm being attached to the side 
by granulations), and deformities may be 
encountered. Calcareous degeneration or 
even epithelioma may attack the scars. 
Pressure upon the terminals of the nerves 
may either cause neuralgia or spasm of 
the glottis, which may demand surgical 
interference for its removal. Finally, 
keloidal tumors may be observed as a 
consequence of vicious scarring. All of 
the scar may not be affected with keloid, 
as, for instance, one end may show the 
prolongations, while the other resembles 
ordinary cicatrices. The contractions of 
the skin after scarring may produce great 
deformit}^ and the hand may be drawn 
backward upon the arm or talipes cal- 
caneus may result or other disfigurations 
too numerous to mention may be shown. 
Exposure of joints has taken place by 
ankylosis. Bones have been fractured 
from loss of substance (cooking of the 
muscles). 

DIAGNOSIS.— Ordinarily the recog- 
nition of burns is not a dithcult task, al- 
though the differentiation of the varieties, 
especially of the second and third degrees, 
may demand careful examination. Burn- 
ing flesh with destruction of its particles^, 
exposure of the underlying tissues (mus- 
cles, bones, etc.), will be a train of symp- 
toms not to be controverted. The dif- 
ference between burns and scalds often 
may occasion difficulty, but the fact of 
the greater and deeper destruction of the 
former with the more superficial charac- 
ter af the latter will generally be suf- 
ficient. The loss of hair follows the for- 
mer because of this deep destruction of 
the hair-follicle and papilla. 

MEDICOLEGAL ASPECTS OF 
BURNS. — In cases where the persons 
have been alive when they were exposed 
to the fire, soot is found in the ramifica- 



SKIN, SURGICAL DISEASES OF 



173 



tions of the trachea and bronchi. If the 
red blood-corpuscles are found disinte- 
grated and disfigured throughout, then 
this is a further sign of a person having 
been burnt while alive. 

The presence of carbon monoxide in 
the blood is an almost positive proof that 
the person during life was not exposed to 
the influence of fire. 

PROGNOSIS.— The termination of this 
class of injuries is often of serious import, 
especially when medicolegal questions 
arise. This should be determined by the 
several factors which arise in each case. 
Consideration must be given to indi- 
viduality of the sufferer, both his age and 
constitutional acquirements; the extent of 
the burn, both as to surface and depth in- 
volved; the location of the injury, and the 
nature of the exciting medium. The ef- 
fects upon strong, robust subjects are 
not so marked as upon those of weaker 
constitutions, and while the same degree 
or extent of burn will soon be recovered 
from by the former, the most dire results 
may follow in the latter persons. Thus it 
may be noticed that burns among ma- 
chinists, glass-blowers, plumbers, and 
foundrymen will not be so serious as 
would the same degree or extent among 
clerks or those engaged in gentlemanly 
pursuits. Colored persons suffer less se- 
verely than do the white. Females, on 
account of more delicate systems, are less 
able to resist shock than are the males. 
Middle life is not so severely affected as 
are children or aged people. Some per- 
sons may be able to resist the shock only 
to be carried off by the complications that 
arise. 

Surface involvement seems to exert a 
greater depression or fatality than does 
depth of tissue. A burn, even of the first 
degree, which occupies an extended area 
and those of the second may terminate 
fatally if one-fourth or one-third of the 
superficial parts are involved; a fatal is- 
sue may also occur in burns occupying 
one-half of the body surface. A burn of 
the second degree which occupies only a 
limited extent of surface, but which de- 
stroys the epidermis entire, may end in 
recovery, while those of the third may, 
through their deep involvement, produce 
complications with which we are unable 



to combat. Burns occupying the abdo- 
men give the highest mortality, while 
those of the thorax are only second to a 
slightly minor extent; but those of the 
head, neck, and limbs prove fatal in 
many instances. Of twenty-six cases seen 
by Sajous after a boiler explosion on the 
Lake of Geneva, in 1892, twenty-two died 
within a few hours after the accident, al- 
though, with few exceptions, the scalds, 
though involving the greater part of the 
body, did not reach beyond the epidermic 
layer, excepting over the face and hands. 

The length of time required for the 
partial or complete reparation of the sur- 
face may be an important question in 
inedicolegal cases. This can only be gov- 
erned by the type of injury, the length of 
contact of the exciting agent, the nature 
of the affected person, and the general 
aspects of the case in question. 

TREATMENT. — Constitutional. — The 
constitutional treatment is to be directed 
toward the relief of pain, the restoration 
of the depressed vitality at the time 
of accident, — i.e., sustaining the system 
throughout the entire restorative process. 
Pain is best relieved by opium, or its al- 
kaloid, morphine (preferably by hypoder- 
mic injection), because these agents have 
little, if any, depressing action upon the 
cardiac functions. The dose required will 
be much greater than ordinarily used, be- 
cause of the sudden character and great 
amount of depression in these injuries. 

Vitality must be restored as quickly as 
possible, and the use of ammonia (prefer- 
ably carbonate), strychnine, and caffeine 
(because of their stimulating effect upon 
the cardiac muscle) ; hot drinks, such as 
milk and tea; alcohol in the form of 
whisky or brandy, and the production of 
local or generalized sweating. A most 
desirable plan of restoring heat is by 
using hot-water bottles placed at regular 
points so as to diffuse its effects. Other 
means, as, for instance, covering the body 
with a sheet and conveying heat through 
a pipe or by placing heated bricks beneath 
this covering. To keep the sufferer fairly 
comfortable during the local treatment 
stimulation must be kept up, care being 
taken not to produce overactivity and thus 
allow reaction to prove as deleterious as 
the effect of the burn. 



174 



SKIN, SURGICAL DISEASES OF. 



Tlic functions of the body must be 
regulated, the bowels being kept free or 
confined, according to the conditions pres- 
ent: the action of the kidneys should be 
watched. In some cases it may be wise 
to anesthetize the patient during the first 
few hours immediately following the burn, 
and especiall}^ during the first dressings 
of aggravated cases. 

Local. — The local treatment is to be 
directed toward the limitation of the re- 
sulting inflammation, the prevention of 
septic infection, assisting the normal 
elimination of the eschar, the develop- 
ment of granulations, and limitation of 
the deformity. 

In burns of the first degree little or 
no treatment may be demanded. In the 
more aggravated cases of this t3'pe the 
application of home measures, such as 
sodium bicarbonate, the white of egg and 
sweet oil (equal parts), lead-water and 
laudanum, and the various hot or cold 
means generally at the disposal of 
housewives. 

Burns of the second and third degrees 
must be more strenuously treated. It is 
often a difficult problem to know which 
is the more soothing application to be 
advised and from which we may get the 
better result. In one case hot applica- 
tions, in another cold; in some wet, and in 
others dry measures are to be given. 
The vesicles, if numerous, should be un- 
touched; but if onl}'^ a few, they are best 
evacuated. 

Prof. S. D. Gross was wont, in many 
mild and severe cases, to use ordinarj- 
white-lead paint; this is a remarkably ef- 
ficacious measure. Mere painting of the 
burn, as if it were an article of furniture, 
etc., causes immediate cessation of the pain. 

The use of carbolized petrolatum (3 to 
6 per cent.), watery solutions of carbolic 
acid (4 per cent.), bismuth subnitrate 
(Vi to 1 dram — 2 to 4 Gm. — to 1 ounce — 
30 Gm. — of ointment of zinc oxide or 
petrolatum), boric acid (either in watery 
saturated solutions or ointments of either 
zinc oxide or petrolatum in strengths 
varA'ing from 6 to 25 per cent.), sodium 
bicarbonate in almost full strength (in 
ointment or watery solutions), and starch 
in varying proportions will usually" be 
found very efficacious. 



Turpentine, where granulations are slug- 
gish, will give excellent results used 
cither in full or diluted strength, giving 
care not to produce too much stimulation. 

When there are large vesicles, these are 
opened on the second or third day. It is 
best to keep the turpentine off the healthy 
skin if possible to avoid local irritation. 

Surgery of this day has placed many 
excellent antiseptics at our disposal, and 
there is no better application than mer- 
cury bichloride in the proportion of 1 to 
lOUO parts of water and kept in constant 
contact, the dressings being made without 
removing the former cloths. 

Ichthyol in watery solutions (1 to 8, 
or stronger, or in glycerin, similar 
strength), or even in from 12 to 36 per 
cent, ointment with zinc oxide or petrola- 
tum and the iodine derivatives, such as 
iodol, aristol, europhen (given preferably 
in ointment 3 to 6 per cent, with petrola- 
tum or lard) are reliable measures. 

Thiol has been found useful for all de- 
grees of burn; it allaj-s pain verj- rapidly 
and arrests cutaneous hyperemia, in this 
manner tending to prevent ulceration and 
scarring. 

Aristol is another valuable agent in 
burns of the second and third degrees, 
and has been found strikingly effective 
where other remedies have failed. 

It may be used in the form of powder 
or mixed with oil or petrolatum. The 
application of aristol powder directly to 
the wound at the beginning hinders the 
dressing from soaking up the secretion; 
when the latter has diminished, however, 
aristol may be applied either alone or in 
a 10 per cent, ointment with olive oil, 
petrolatum, and lanolin. 

Many authoritative surgeons have lauded 
picric acid used in saturated solutions 
with water (increasing the solubility by 
means of the addition of 1 ounce — 30 
c.c. — of alcohol, as the acid is soluble to 
the extent of only 2 drams — 8 Gm. — to 
the quart — liter — of water). It is par- 
ticularly useful for the relief of pain 
and it greatly assists the formation of 
granulations. . 

The combination of picric and citric 
acids, which Esliach devised for the de- 
tection of albumin, is more effective than 
the picric acid alone, in burns of the sec- 



SKIN, SURGICAL DISEASES OF. 175 

ond degree. Esbach's solution consists of Granulations may often be assisted by 

10 parts of picric acid, 20 of citric acid, powders of acetanilide in full strength, or 

and KKX) of water. The bullae and vesi- with equal parts of boric acid, dusted over 

cles should, be opened with a clean blade the area, or by means of iodol, europhen 

and the fluid applied freely. Repeated ap- or aristol (3 to 12 per cent.) with powdered 

plication of tincture of ferric chloride is starch or in ointment. Scarlet red in 10 

another useful form of treatment. Cal- per cent, solution may also be used. 

cined magnesia, in a paste made with Limitation of deformity is often a seri- 

water, is serviceable in l)urns of the first ous problem though in some measure ob- 

and second degrees. Iodoform, as an viated by paraffin treatment. Splints may 

analgesic and antiseptic, may be left in be utilized and they should be kept applied 

situ for some time. Potassium nitrate for some time after the parts have healed 

solution is useful, chiefly as refrigerant. because of the inherent tendency to the 

The paraffin treatment of severe burns contraction for long periods, even years, 

constitutes a distinct advance over the pro- after an apparent cure. Bandages are to 

cedures previously in general use. Be- be kept continuously applied to prevent 

sides forming a painless dressing, which contiguous surfaces from becoming ag- 

is easy of application and removal, and glutinated. Massage must be advised at 

does not favor infection, it results in more the very earliest moment so as to restore 

rapid healing, and leaves a smooth, soft, the pliability of the part and prevent anky- 

pliable scar, with little or no tendency to losis when a joint is involved. Even with 

contracture and deformity. Either am- all the measures that we can adopt the 

brine or one of the numerous substitutes loss of skin-tissue may be so extensive 

for it may be used. The burn is first that skin-grafting will be the only means 

washed with sterile water, saline solution, with which we can hope to restore the 

or boric acid solution; it may be sprayed integrity of the part. The relief of cica- 

with a 3 to 5 per cent, solution of dichlo- trices or contractions, ankylosis, or pres- 

ramine-T, followed, if necessary, by liquid sure upon the nerve-filaments sometimes 

petrolatum to allay pain. It is then dried requires the most energetic surgical in- 

with sterile gauze or an electric dryer, and terference. 

the paraffin preparation applied with a TREATMENT OF ELECTRICAL 
broad camel's hair brush or special sprav BURNS. — Elder advises that the part sub- 
apparatus. Shere recommends the follow- jected to the burn be immersed and kept in 
ing mixture: ^ warm carbolic-lotion bath, 1 per cent., 

,,„ . ,. ic ^,,„,^^ taking precautions against the possibility 

White vaseline 15 ounces. , ,,"' ^ % i u 

,...,,, ^ 9 ^,,„ooc of the occurrence of secondary hemor- 

Liquid petrolatum Z ounces. -' 

Oil of euealyptus 1 ounce. --hage. If secondary hemorrhage occur or 

Paraffin (melt. pt. 42.7° C.) .. 16 ounces. ^hen a definite Ime^ of demarcation has 

formed, the necrosed tissue must be re- 

Iv lute uax. J T , ,. . 

„. , J. , , T/ ^,,„„„ moved. In many cases amputation is 

Pix burgundica, of each ^ ounce. ,.., ,-r, i,, .u 

necessary, but the skin-Haps should not be 

For the first few days, 1 dram each ot closed, because large masses of muscle are 

thymol, iodide and menthol are added to gm-e to slough away subsequently. The 

allay infection and pain; later, >2 to 1 per wound should be allowed to granulate, 

cent, of scarlet red, and when epithclializa- and subsequently be skin-grafted. Imme- 

tion is nearly complete, bismuth subgal- diately after the burn hypodermic injec- 

late, 1 to 10. A thin layer of cotton is tions of morphine (% grain — 0.01 Gm.) 

placed over the first layer of paraffin, a and strychnine (V.s(» grain — 0.002 Gm.) may 

second paraffin coating applied, and the j^g given alternately. To lessen the oft'en- 

dressing completed with cotton and band- give odor the 1 per cent, carbolic lotion 

age. Redressing is done daily at first, niay be replaced by a bath of 1 in 10,000 

later on alternate days. mercury bichloride. In addition, mor- 

The lethal tendency of burns is best phine, phenacetin, caffeine, chloral hydrate, 

met by removing the necrosed tissues and and potassium bromide may be adminis- 

infusion of saline solution, repeated daily. tered together. 



176 



SODIUM (SAJOUS). 



Immobilization of the part aiul protec- 
tion with sterile gauze arc necessary, 
and, if the hum is extensive, skin-grafting. 

SCAR-TISSUE DEFORMITIES.— 

Scars, even when adherent to hones, j)ain- 
ful thickenings following injuries or hums, 
or of the tendons, are favorably influenced 
by X-rays. Grace (Am. Jour, of Pllectr. 
and Radiol., Oct., 1919) uses a filter of 
1 mm. of aluminium for the superficial 
cases and of 2 mm. for the deeper. The 
Palzsche method, a salve composed of 
pepsin, hydrochloric acid, and phenic acid, 
each 1 per cent., rubbed into the scar twice 
daily, is also effective according to Schues- 
sler (Miiench. med. Woch., Ixviii, 72, 1921). 
Moist compresses are applied at night. 

C, W. and S. 

SODIUM* — Sodium, or natrium, is 
a light, soft, ductile, malleable metal, 
of silver-white luster when freshly cut, 
and of dull-gray color when oxidized 
by air. Like potassium, it has a strong 
afifinity for oxygen, and must be kept 
immersed in a liquid free from oxy- 
gen, such as benzene or naphtha. 
Thrown upon water, it burns with a 
bright yellow flame, imiting with the 
oxygen of some of the water and 
forming in the remainder a solution of 
sodium hydroxide. The pure metal is 
not used in medicine, but yields a 
larger number of official compounds 
than any other element. 

Upon a therapeutic basis, the fol- 
lowing classification of some of the 
sodium compounds may be made : — 

Caustics: Soda, and soda with lime 
(unofficial). 

Purgatives: Sodium phosphate, sodium 
sulphate, and potassium and sodium tar- 
trate. 

Systemic antacids: Sodium acetate, so- 
dium bicarbonate, monohydrated sodium 
carbonate, sodium citrate, and potassium 
and sodium tartrate. 

Diuretics: Sodium acetate, sodium ben- 
zoate, sodium bicarbonate, monohydrated 
sodium carbonate, sodium citrate, and 
potassium and sodium tartrate. 



Febrifuges: Sodium acetate, sodium 
benzoate, sodium citrate, and sodium 
salicylate. 

Antiseptics: Sodium benzoate, sodium 
borate, sodium chlorate, sodium hypo- 
chlorite, sodium phenolsulphonate, and 
sodium salicylate. 

PREPARATIONS AND DOSES. 

— The official preparations of sodium 
are: — 

Sod a hydroxidnm, U. S. P. (sodium 
hydroxide or hydrate: caustic soda), 
rapidly deliquescent, and acquiring a 
coating of sodium carbonate; soluble 
in 1 part of water and freely in alcohol. 

Liquor sodii hydroxidi, U. S. P. 
(solution of sodium hydroxide), of 
about 5 per cent, strength. Dose, 10 
to 30 minims (0.6 to 2 c.c). 

Liquor soda chlorinata, U. S. P. 
(solution of chlorinated soda; Labar- 
raque's solution), an aqueous solution 
of several chlorine compounds of so- 
dium, containing at least 2.4 per cent. 
by weight of available chlorine. Dose, 
10 to 30 minims (0.6 to 2 c.c). 

Sodii acetas, U. S. P. (sodium 
acetate), soluble in 1 part of water 
and in 23 parts of alcohol. Dose, 10 
to 30 grains (0.6 to 2 Gm.). 

Sodii arsenas, U. S. P. (sodium ar- 
senate). Dose, Yxo grain (0.006 Gm.). 
(See Arsenic.) 

Sodii arsenas exsiccatus, U. S. P. 
(dried sodium arsenate). Dose, %o 
grain (0.003 Gm.). (See Arsenic.) 

Liquor sodii arscnatis, U. S. P. 
(solution of sodium arsenate). Dose, 
3 minims (0.2 c.c). (See Arsenic.) 

Sodii henzoas, U. S. P. (sodium 
benzoate), soluble in 1.6 parts of 
water and in 43 parts of alcohol. Dose, 
10 to 20 grains (0.6 to 1.3 Gm.). (See 
i^ENzoic Acid.) 

Sodii bicarhonas, U. S. P. (sodium 
bicarbonate, acid sodium carbonate, 
baking soda), soluble in 12 parts of 



SODIUM (SAJOUS). 



177 



water, insoluble in alcohol ; converted 
into sodium carbonate on boiling its 
solution. Dose, 10 to 60 grains (0.6 
to 4 Gm.). 

Sodium bicarbonate should only be 
given in small doses (12 to IS grains 
— 0.75 to 1 Gm.) several times daily. 
The acidity is tlius diminished suffi- 
ciently to reduce the pain, yet an 
increased flow of acid is not stimu- 
lated. It has been proven that 15 to 
45 grains (1 to 3 Gm.) given before, 
during, or after a test-meal will favor 
the passage of the food from the 
stomach into the intestines, while 
larger doses may cause a spasm. 
Even if the drug is given for a long 
time in the doses mentioned, cachexia 
will not set in. The fear that over- 
loading of the blood with sodium 
may lead to increased production of 
hydrochloric acid is very remote. E. 
Binet (Progres med., 3, 1911). 

Trocliisci sodii bicarbonatis, U. S. P. 
(troches or lozenges of sodium bicar- 
bonate), each containing 3 grains (0.2 
Gm.) of the bicarbonate and Vq grain 
(0.01 Gm.) of nutmeg. 

Mistura rhei composita, N. F. (mix- 
ture of rhubarb and soda). Dose, 2 
fluidrams (8 c.c). (See Rhubarb.) 

Sodii bisulphis, U. S. P. VIII 
(sodium bisulphite; acid sodium sul- 
phite; leucogen), unpleasant in taste, 
gradually oxidized to sulphate on ex- 
posure to air, soluble in 3.5 parts of 
water and in 70 parts of alcohol. 
Dose, 7y2 grains (0.5 Gm.). 

Sodii boras, U. S. P. (sodium borate; 
borax), soluble in 20.4 parts of cold 
water, in 0.5 part of boiling water, and 
in 1 part of glycerin, with which it 
reacts to form boroglyceride, with evo- 
lution of gas ; insoluble in alcohol. 
Dose, yj/z grains (0.5 Gm.). (See 
I!oRic Acid.) 

Sodii bromidum, U. vS. P. (sodium 
bromide). Dose, 10 to 60 grains (0.6 
to 4 Gm.). (See Bromine.) 

8—12 



Sodii carbonas monohydratus, U. S. P. 
(monohydrated sodium carbonate), 
containing only one molecule of water 
of crystallization, and therefore nearly 
twice as strong as the ordinary soditmi 
carbonate ; soluble in 2.9 parts of water 
and in 8 parts of glycerin, insoluble in 
alcohol. Dose, 4 grains (0.25 Gm.). 

Sodii cyanidnm, U. S. P. (sodium 
cyanide), deliquescent and smelling of 
hydrocyanic acid ; freely soluble. 

Sodii glyccrophosplias, U. S. P. 
(sodium glycerophosphate), saline in 
taste ; freely soluble. Dose, 4 grains 
(0.25 Gm.). 

Sodii chloridum, U. S. P. (sodium 
chloride; salt), at least 99 per cent, 
pure, soluble in 2.8 parts of water, 
almost insoluble in alcohol. Dose, as 
emetic, 4 drams (16 Gm.). 

Sodii citrus, U. S. P. (sodium ci- 
trate), with a cooling, saline taste; 
soluble in 1.1 parts of water, slightly 
soluble in alcohol. Dose, 10 to 60 
grains (0.6 to 4 Gm.). 

Sodii hypophosphis, U. S. P. (so- 
dium hypophosphite), very deliques- 
cent, soluble in 1 part of water and 
in 25 parts of alcohol. Dose, 5 to 30 
grains (0.3 to 2 Gm.). (See Phos- 
phoric Acid.) 

Syrupus hypophosphitum, U. S. P. 
(syrup of hypophosphites). Dose, 1 
to 2 fluidrams (4 to 8 c.c). (See 
Phosphoric Acid.) 

Sodii indigotindisulphonas, U. S. P. 
(indigo carmine), a blue powder or 
purple paste ; sparingly soluble in 
water, yielding a dark blue solution. 

Sodii iodidum, U. S. P. (sodium 
iodide). Dose, 5 to 60 (0.3 to 4 Gm.). 
(See Iodine.) 

Sodii nitras, U. S. P. VIII (sodium 
nitrate; Ghili saltpeter; cubic niter), 
with a cooling, saline, slightly bittei 
taste; soluble in 1.1 parts of water and 



178 SODIUM (SAJOUS). 

in about 100 parts of alcohol. Dose, cent in the air; soluble in 2.8 parts 

5 to 15 grains (0.3 to 1 Gm.). of water and in glycerin, insoluble in 

Sod a nit r is, U. S. P. (sodium ni- alcohol. Dose, 1 to 8 drams (4 to 32 

trite). Dose, 1 grain (0.06 Gm.). Gm.). 

(See Nitrites.) Sodii sidpJiis exsiccatus, U. S. P. 

Sodii phcnolsidphonas, U. S. P. (so- (sodium sulnhitcV with saline, sulphur- 

dium phenolsulphonate or sulphocar- ous taste ; soluble in 2 parts of water, 

bolate), with a cooling, saline, bitter sparingly soluble in alcohol. Dose, 15 

taste; soluble in 4.8 parts of water and grains (1 Gm.). 

in about 130 parts of alcohol. Dose, Sodii thiosidpJias, U. S. P. (sodium 

4 grains (0.25 Gm.), thiosulphate or hyposulphite), with a 

Sodii phosphas, U. S. P. (sodium cooling, afterward bitter, taste; solu- 

phosphate; disodium hydrogen ortho- ble in about 0.35 part of water, 

phosphate), efflorescent in the air; slightly soluble in oil of turpentine, 

soluble in 5.5 parts of water, insoluble insoluble in alcohol ; the aqueous solu- 

in alcohol; an aqueous solution, is tion is rapidly decomposed by boiling, 

slightly alkaline to htmus. Dose, 30 Dose, 5 to 20 grains (0.3 to 1.25 Gm.). 

grains to 4 drams (2 to 15 Gm,). (See Potassii et sodii tartras, U. S. P. 

Phosphoric Acid.) (Rochelle salt). Dose, 1 to 8 drams 

Sodii phosphas cffervescens, U, S. P. (4 to 30 Gm.). (See Potassium.) 

(effervescent sodium phosphate), con- Among the sodium preparations 

taining 20 per cent, of exsiccated so- recognized in the National Formulary 

dium phosphate, together with sodium are the following: — 

bicarbonate, tartaric acid, and citric Soda cum cake, N. F, (soda with 

acid. Dose, 2 to 8 drams (8 to 30 lime; London paste), a paste consist- 

Gm,), (See Phosphoric Acid.) ing of sodium hydroxide and imslaked 

Sodii phosphas cxsiccatns, U. S. P. lime in equal parts, employed as escha- 

(dried sodium phosphate). Dose, 15 rotic. 

grains to 2 drams (1 to 8 Gm.). (See Liquor antisepticus alkalinus, N, F. 

Phosphoric Acid.) (alkaline antiseptic solution, contain- 

Sodii perhoras, U. S. P. (sodium ing, among other substances, sodium 

perborate) ; gives off 9 per cent, of borate, sodium benzoate, and oil of 

oxygen in warm or moist air; white gaultheria. (See Salicylic Acid.) 

crystalline granules or powder; soluble Liquor sodii arsenatis, Pearson, N.F. 

in water. Dose, grain (0.06 Gm.). (Pearson's solution). (See Arsenic.) 

Liquor sodii phosphatis compositus, Liquor hypophosphitum, N. F, (solu- 

U. S, P. (compound solution of sodium tion of hypophosphites). Dose, 1 

phosphate), a 100 per cent, solution of fiuidram (4 c.c). To replace the offi- 

sodium (citro) phosphate, containing cial syrup of hypophosphites when 

also 4 per cent, of sodium nitrate, sugar is to be avoided. 

Dose, ^ to 4 fluidrams.(2 to 16 c.c). Liquor hypophosphitum compositus, 

Sodii salicylas, U. S. P. (sodium N. F. (compound solution of hypo- 

salicylate). Dose, 15 grains. (See phosphites). Dose, 1 fluidram (4 c.c). 

Salicylic Acid.) Liquor sodii boratis compositus, N.F. 

Sodii sulphas, U. S. P. (sodium sul- (Dobell's solution), containing phenol, 

phate; glauber salt), rapidly efflores- 0.3 per cent.; sodium borate and bi- 



SODIUM (SAJOUS). 



179 



carbonate, of each, 1.5 per cent., and 
glycerin, 3.5 per cent., in sterile water. 

Liquor sodii carbolatus, N. F. Ill 
(carbolated soda solution), consisting 
of phenol, 50 per cent, in water, to- 
gether with sodium hydroxide, 3.5 per 
cent. 

Liquor sodii citratis, N. F. (solution 
of sodium citrate; potio Riveri), made 
from citric acid, 2 per cent., and so- 
dium bicarbonate, 2.5 per cent., in 
water. Dose, 2 fluidrams (8 c.c). 

Liquor sodii citrotartratis cffcrvcs- 
ccns, N. F. (tartrocitric lemonade). 
Dose, 12 flviidounces (360 c.c). 

Liquor sodii oleatis, N. F. Ill (solu- 
tion of soap). 

Elixir sodii hromidi, N. F. (elixir of 
sodium bromide). Dose, 2 fluidrams 
(8 c.c), containing 20 grains (1.3 Gm.) 
of the bromide. 

Elixir sodii hypophosphitis, N. F. 
(elixir of sodium hypophosphite). 
Dose, 1 fluidram (4 c.c). 

Elixir sodii salicylatis, N. F. (elixir 
of sodium salicylate). Dose, 1 fluidram 
(4 c.c). (See Salicylic Acid.) 

Syrupus bromidorum, N. F. (syrup 
of the bromides). Dose, 1 fluidram (4 
c.c). 

Syrupus calcii et sodii hypophos- 
phitum, N. F. (syrup of calcium and 
sodium hypophosphites). Dose, 1 flui- 
dram (4 c.c). 

Syrupus sodii hypophosphitis, N. F. 
(syrup of sodium hypophosphite). 
Dose, 1 fluidram (4 c.c). 

Liquor soda et nienthcc, N. F. (soda 
mint solution), consisting of aromatic 
spirit of ammonia, 1 part ; sodium bi- 
carbonate, 5 parts, in spearmint-water, 
enough to make 100 .parts. Dose, 2 
fluidrams (8 c.c). 

Syrupus hypophosphitum composi- 
tns, N. F. (compound syrup of hypo- 
phosphites), containing hypophosphites, 



quinine, and strychnine. Dose, 2 
fluidrams (8 c.c). 

Sodii borobcncoas, N. F. (sodium 
borobenzoate), a mixture of sodium 
borate, 3 parts, with sodium benzoate, 
4 parts. Dose, 10 to 30 grains (0.6 to 
2 Gm.). 

Sal Carolinum factitiiim, N. F. (ar- 
tificial Carlsbad salt), an amorphous 
powder consisting of sodium sulphate 
(dried), 18 parts; sodium bicarbonate, 
36 parts; sodium chloride, 18 parts, 
and potassium sulphate, 28 parts. To 
be dissolved in 200 parts of water. 
Dose, 6 fluidounces (200 c c), repre- 
senting an equal volume of Carlsbad 
water (Sprudel). If the crystalline 
preparation of the same nature be used, 
1.75 parts of the salt are to be dis- 
solved in 200 parts of water. 

Sal Kissingcnse factitium, N. F. 
(artificial Kissingen salt), consistmg of 
sodium chloride, 357 parts ; sodium 
bicarbonate, 107 parts; magnesium sul- 
phate (anhydrous), 12 parts, and 
potassium chloride, 17 parts. One and 
a half parts of the salt are to be dis- 
solved in 200 parts of water. Dose, 
6 fluidounces, representing an equal 
volume of Kissingen water (Rakoczy). 

Sal Vichy anum factitium, N. F. (ar- 
tificial Vichy salt), composed of so- 
dium bicarbonate, 846 parts ; sodium 
chloride, 77 parts, and magnesium sul- 
phate (anhydrous) 80 parts, and po- 
tassium carbonate, 38 parts. To be 
dissolved in 200 parts of water. Dose, 
6 fluidounces (200 cc), representing 
an equal volume of Vichy water 
(Grande Grille spring). 

Pulvis satis Carolini factitii effcr- 
vcsccns, N. F. (efi^ervescent artificial 
Carlsbad salt). Dose, 90 grains (6 
Gm.) in 6 ounces (200 c.c.) of water. 

Pulvis salts Kissingensis factitii ef- 
fervescens, N. F. (effervescent artifi- 



180 SODIUM (SAJOUS). 

cial Kissingen salt). Dose, 80 grains Small amounts of salt have been found 

(5.5 Gm.) in 6 fluidounces (200 c.c.) at times to lessen the acidity of the 

of water. gastric juice, but the greater palatabil- 

Pulzns salis Vichyani factitii effer- ity of food seasoned with salt may 
vescens, N. F. (effervescent artificial counteract this Ijy augmenting the re- 
Vichy salt). Dose, 57 grains (3.75 flex gastric secretion. The salivary 
dm.) in 6 fluidounces (200 c.c.) of flow is increased by salt, partly through 
water. reflex action and partly because some 

Piilvis salis Vichyani factitii effer- of it is excreted by the salivary glands. 

vcsccns cum lithio, N. F. (efifervescent Absorption of ingested hypotonic 

artificial Vichy salt with lithium), solutions of salt takes place chiefly 

Dos.e, 90 grains (6 Gm.), representing from the intestine, and results in a 

14 grains (1 Gm.) of artificial Vichy diluted condition of the blood — hydre- 

salt and 5 grains (0.3 Gm.) of lithium mia — which induces diuresis. The flow 

citrate. of urine is increased more by direct 

PHYSIOLOGICAL ACTION.— saline infusion into the blood than by 

Sodium as an element or ion exerts in saline solution (or water) absorbed 

moderate amounts, different from po- from the stomach and bowel. Hyper- 

tassium, little or no effect upon the tonic salt solution injected into the 

tissues of higher animals. That the blood causes marked diuresis through 

sodium ion may exert a deleterious ac- absorption of water from the body tis- 

tion on some animal cells is shown, sues, but hypertonic salt solution in- 

however, by the observation that some gested causes little or no diuresis, as 

ova and fish ordinarily inhabiting sea- the salt is only slowly absorbed from 

water survive longer when placed in it, and though tending, for a time, to 

distilled water than when placed in a increase the total bulk of the blood, 

solution of sodium chloride isotonic does not render it hydremic, 

with sea-water. More concentrated Sodium hydroxide (caustic soda), 

solutions of sodium chloride, in addi- like potassium hydroxide and calcium 

tion to a possible ionic poisonous ef- oxide, is a strong caustic, destroying 

feet of the kind just described produce tissue by abstraction of water, dissolu- 

the effects characteristic of "salt ac- tion of albumin, and saponification of 

tion" in general, viz., withdrawal of fats. Similar effects are produced by 

water from cells, with corresponding liquor sodii hydroxidi and by soda cum 

shrinkage of the latter and, where the calce (N. R). 

occasion presents, effects due to irrita- Sodium hypochlorite, official in the 

tion, such as vomiting in the case of liquor sod?e chlorinatse or Labarraque's 

the stomach. solution, gives off chlorine and pos- 

According to the experiments of sesse? the antiseptic, deodorant, and 

Miinch, exhibition for a few days of bleaching properties of the latter. It 

large quantities of sodium chloride in is decidedly irritating to the tissues, 

man causes at first a slight decrease but this property may be reduced, 

in excretion (especially renal), with a seemingly without loss of antiseptic 

corresponding gain of body weight; power, by the addition of suf^cient 

after a time, however, the excretions boric acid to neutralize the free alkali 

-ncrease and the weight decreases, in the preparation. 



SODIUM (SAJOUS). 



181 



Sodium acetate, like other salts of 
alkalies with the vegetable acids, is 
rapidly absorbed and oxidized in the 
system to form sodium carbonate, 
which increases the alkalinity of the 
blood and urine, and causes diuresis. 
Over direct ingestion of alkaline car- 
bonates or bicarbonates, sodium acetate 
and similar salts have the advantage 
of not neutrahzing the gastric juice. 

Sodium bicarbonate, applied in solu- 
tion to mucous membranes, exerts a 
soothing effect, and tends to dissolve 
thick mucus. It is mildly alkaline, but 
the alkalinity of its solutions increases 
on standing, because of the loss of 
carbon dioxide. Applied in dilute solu- 
tion to isolated contractile organs, in- 
cluding vessel-walls and ciliated epi- 
thelium, it causes for a time, like other 
dilute alkalies, increased activity and 
tonicity, and in certain protozoa an 
increased resistance to asphyxia from 
oxygen exclusion; later, the augmented 
activity is replaced by depression. 

Experiments in dogs have shown 
that the alkaline carbonates, adminis- 
tered internally, do not influence the 
rate of gastric secretion. They tend, 
however, to increase gastric motility 
by virtue of the carbon dioxide liber- 
ated through reaction with the hydro- 
chloric acid of the gastric juice, and 
may also in themselves, by inducing 
slight local irritation, exert a mild 
carminative effect, relieving gaseous 
distention and the consequent pain. 
Five grains (0.3 Gm.) of sodium bi- 
carbonate, if completely utilized in the 
destruction of the gastric acid, are 
capable of neutralizing about 1^ 
ounces of gastric juice of 0.3 per cent, 
strength. Where the stomach contains 
no acid, as in the resting period be- 
tween the digestion of successive meals, 
sodium bicarbonate simply dissolves the 



gastric mucus and is absorbed un- 
changed. Neutralization of the gastric 
acid has been held to reduce pancreatic 
secretion, the normal stimulus to the 
pancreas resulting from the entrance 
of acid into the duodenum having been 
partly or completely removed. In gas- 
tric hyperacidity, however, it may, 
nevertheless, be beneficial by allaying 
excessive irritation by the gastric acid 
in the duodenum, thereby relieving 
catarrh of the latter. Stadelmann and 
others have shown that alkalies exert 
no direct influence on the secretion or 
reaction of the bile, in spite of former 
views to the contrary. According to 
some, sodium bicarbonate exerts a mild 
laxative effect. Once absorbed into the 
blood, sodium bicarbonate increases the 
alkalinity of the latter, though its rapid 
excretion renders it difficult to obtain 
a lasting result in this respect. The 
acidity of the urine is reduced and its 
total output increased; where enough 
has been given to render the urine 
alkaline, sodium bicarbonate may be 
found in it unchanged. 

Sodium bicarbonate always stimu- 
lates the gastric secretions. In hy- 
perchlorhydria it should be given in 
large doses some time after meals, 
so that the food can leave the stoin- 
ach before the excessive acidity of 
the chyme has been restored. The 
drug has a remarkable soothing ac- 
tion on the tardy pain of digestion, 
even in secretory insufficiency. In 
hypochlorhydria the best results are 
obtained with an interval of two 
hours before the meal for a dose of 
0.5 Gm. (7.5 grains); three hours for 
twice this dose, and four hours for 
a dose of 5 Gm. (75 grains). Very 
small doses can be given even with 
the meals. The drug renders the 
stomach content alkaline, and under 
the stimulation of this the secretions 
gradually pour out to neutralize the 
alkalinity, and normal acidity is thus 



182 



SODIUM (SAJOUS). 



in time regained or even surpassed. 
Linossier (Bull, de I'Acad. de Med., 
Apr. 14, 1908). 

Sodium carbonate, official as the 
monohydrated salt, is more strongly 
alkaline than the bicarbonate, though 
far less corrosive than sodium hydrox- 
ide, and causing manifest injury to 
the skin only after very protracted con- 
tact. The efifects of ingested sodium 
carbonate are the same as those of the 
bicarbonate, though the salt is more 
irritating than the bicarbonate. Inves- 
tigations have shown that alkalies 
exert little or no effect on the total 
output of nitrogenous wastes, though 
the ammonia of the urine is often di- 
minished and the urea correspondingly 
augmented, especially in individuals 
with an excess of acid in the tissues, 
the alkalies neutralizing acid which 
would otherwise excite the production 
of ammonia in the system. No definite 
change in uric acid metaboHsm from 
alkaline medication has been detected. 
Rabbits treated with alkalies exhibit 
greater resisting power to anthrax in- 
fection than controls. The reaction of 
the urine is strongly affected by sodium 
carbonate, 2>4 to 4 drams (10 to 15 
Gm.) of the salt in twenty- four hours 
being nearly always sufficient to pro- 
duce and maintain an alkaline condi- 
tion; an alkaline reaction lasting two 
or three hours may often be brought 
about by a single dose of 30 to 45 
grains (2 to 3 Gm.) (Cushny). 

Sodium chlorate possesses the same 
therapeutic and toxic properties as po- 
tassium chlorate. (See Potassium.) 

Sodium citrate, like potassium citrate 
and sodium acetate, is absorbed from 
the intestine, probably after partial de- 
composition by hydrochloric acid in the 
stomach, and is then quickly and com- 
pletely oxidized in the system to form 



sodium carbonate. Sodium citrate be- 
ing less readily absorbed than the ace- 
tate, a cathartic effect is more likely to 
result, provided a fairly large amount, 
isuch as 30 grains (2 Gm.), is given. A 
portion of the drug is, however, ab- 
sorbed and exerts alkalinizing and 
diuretic effects. Citrates prevent or 
delay the coagulation of blood and the 
clotting of milk by rennin, owing to 
their affinity for calcium. Introduc- 
tion of the citratei into the system ap- 
parently does not, however, produce 
such an effect on the circulating blood, 
doubtless because it is promptly changed 
to the carbonate. 

Sodium nitrate exerts chiefly a di- 
uretic effect, though it is considered 
somewhat inferior to potassium nitrate 
in this connection. The diuresis is gen- 
erally ascribed to the salt-action of the 
drug exerted in the blood-stream, but 
the possibility of a direct excitant ef- 
fect on the kidney is also recognized. 
Moderate amounts of the nitrates, when 
ingested, fail to appear in the urine as 
such, apparently being broken down in 
the system, probably in, part to nitrites 
and ammonia. The specific action of 
the nitrate ion is to cause irritation of 
any mucous surface with which it 
comes in contact. The nitrates should 
always be given well diluted, and ad- 
ministered only with caution in the 
presence of gastrointestinal irritation, 
as they produce such irritation them- 
selves when given in large amounts. 

Sodium phenolsulphonate (sulpho- 
carbolate) is absorbed and excreted 
unchanged. It has antiseptic proper- 
ties, is less toxic than phenol, and has 
been used internally to check gastric 
fermentation. 

Sodium sulphate (Glauber's salt) is 
only with difficulty absorbed from the 
intestinal tract, and exerts a purgative 



SODIUM (SAJOUS). 183 

action by increasing the fluid content Sodium thiosulphate (hyposulphite) 

of the bowel. If administered in a acts like the preceding salts, but is 

relatively small amount of water, it oxidized in the system with greater 

draws more water from the surround- difficulty, a considerable proportion 

ing tissues by salt action as it passes passing out unchanged in the urine. It 

down; if given, on the other hand, in is credited with much value as a 

a large amount of water, it merely deodorant. 

keeps this water from being absorbed, POISONING BY SODIUM AND 
thus again producing an abnormal fluid- ITS SALTS. — The sodium salts, as 
ity of the intestinal contents. The a whole, are less poisonous than those 
small proportion of the salt which is of potassium, as they lack the direct 
absorbed into the blood — this propor- toxic action of potassium on the 
tion varying inversely with the amount heart. Sodium salts given in two or 
of the drug given, the larger amounts three times the quantity which would 
producing more rapid evacuation — prove fatal in the case of potassium 
causes a hydremia and consequent di- salts, produce no effect on the system 
uresis, which occurs later than with except a passing weakness. Sodium 
sodium chloride, owing to the slower hydroxide, however, is a powerful 
absorption of the sulphate. The more corrosive, and leads to serious re- 
marked the purgative effect, the less suits when ingested by mistake, or 
pronounced the diuretic. Recent in- — uncommonly — for the purpose of 
vestigations have not substantiated the suicide. 

view that sodium sulphate and other SODIUM HYDROXIDE. — Strong 

saline cathartics increase the secretion solutions of caustic soda, placed in 

of bile. contact with the tissues, tend to 

Notwithstanding its harsh, unpleas- penetrate deeply by dissolving pro- 
ant taste, sodium sulphate is relatively teins, and produce marked destruc- 
non-toxic to tissues in general, and may tion of tissue. The semitransparent 
be administered in large amounts with- crust at first" formed usually drops off 
out inconveniences other than those of after some days, an ulcer remaining 
salt action. which is slow to heal. 

Sodium sulphite and sodium hisul- Taken internally, concentrated so- 
phitc act as deoxidizers, absorbing lutions of sodium hydrate produce 
oxygen from organic matter to become marked corrosion of the mouth, ex- 
transformed into sulphates. Practically tending down to the throat, esoph- 
all of each of these salts that is ab- agus, and stomach. In the latter, 
sorbed is oxidized in this way. Given perforation resulting in peritonitis 
internally in not too large amounts the may occur; or, death may take place 
sulphites thus act as non-toxic, though from the widespread destruction of tis- 
rather irritating, antiseptics. Rapid ab- sue, or, later, from gradual starvation 
sorption of large quantities, however, due to cicatricial obstruction in the ali- 
brings about the true sulphite action, mentary passages. 

which consists of depression of the Treatment of Poisoning by Sodium 

medullary centers and circulatory mus- Hydroxide. — This comprises the ad- 

culature, with death from asphyxia as ministration of dilute acids, prefer- 

a possible termination. ably of the vegetable group, such as 



184 



SODIUM (SAJOUS). 



acetic, citric, or tartaric acid, which 
are often available in the form of 
vinegar, or lemon-juice. Passage of 
a stomach-tube is dangerous, as it 
might penetrate the corroded gastric 
wall. 

Olive oil, lard, white of egg, or 
milk, should be given as demulcents. 
Morphine may be given to alleviate 
the pain. Stimulants may be re- 
quired to combat collapse ; external 
heat should also be applied under 
these circumstances. Later, the pas- 
sage of bougies or surgical proced- 
ures to overcome stenosis may be 
necessary. 

SODIUM BICARBONATE AND 
CARBONATE.— Sodium bicarbonate 
is free of caustic action, but the car- 
bonate may corrode tissues when ap- 
plied for some time in concentrated 
solution. Giving large amounts of 
the alkaline carbonates and bicar- 
bonates to animals has been observed 
to induce a chronic gastroenteric in- 
flammation, which may prove fat-al. 

Sodium bicarbonate in large doses, 
such as 300 grains (20 Gm.) or more 
daily, may cause an increase in body 
weight, due to retention of chlorides 
with resultant water retention, which 
may go on to the appearance of 
edema. This condition is most likely 
to appear during the administration 
of the bicarbonate to cachectic dia- 
betics with acidosis, but it can be 
produced in an experimental way in 
normal individuals. L. A. Levison 
(Jour. Amer. Med. Assoc, Jan. 23, 
1915). 

SODIUM CHLORIDE. — Serious 
symptoms and frequently death have 
resulted from the introduction of a 
large quantity of sodium chloride into 
the system. Such poisoning occurs 
oftenest from the inadvertent use of 
a strong salt solution instead of nor- 
mal saline solution for proctoclysis or 



intravenous infusion, but is reported 
also to be a common method of sui- 
cide in one of the provinces of China, 
a pint or more of saturated salt solu- 
tion being ingested for this purpose. 
Combs reported a fatal case, with 
crenation of the erythrocytes in fresh 
blood, in a woman who received about 
4 ounces (120 Gm.) of salt in a strong 
solution by hypodermoclysis. 

The symptoms of sodium chloride 
poisoning consist of nausea, vomiting, 
diarrhea, fever up to 104° F. (40° C), 
delirium or coma, and fatal collapse. 
In cases with diminished renal per- 
meability and salt retention, as in 
nephritis or eclampsia, even normal 
saline solution may increase edema 
and induce edema of the lungs, or the 
v^omiting of fluid rich in chlorides 
(Bastedo). Marked edema of the 
legs from prolonged use of large 
amounts of salt with the meals has 
also been reported. 

Case of a healthy boy of 5 years 
who received an injection of strong 
brine as a domestic remedy for 
worms. The mother made the mis- 
take of putting a pound instead of 
a tablespoonful of salt in a quart of 
water. In five or ten minutes the 
child was taken with pain in the 
head, intense thirst, and vomiting, 
soon followed by severe purging. In 
thirty minutes he had become un- 
conscious, and one convulsion fol- 
lowed another until death occurred 
five hours after the injection. O. H. 
Campbell (Jour. Amer. Med. Assoc. 
Oct. 5. 1912). 

SODIUM NITRATE. — The ni- 
trates, in excessive amount, especially 
if taken in concentrated form, cause 
gastric pain, nausea, vomiting, and 
sometimes diarrhea. Blood may be 
eliminated with the vomitus and 
stools. Either diuresis or oliguria 
may be noted. Further symptoms 



SODIUM (SAJOUS). 



185 



are motor weakness, mental dullness, 
collapse, and . coma, terminating in 
death. Dilute nitrate solutions may 
be taken in large amount without 
trouble, but the more concentrated 
ones induce the symptoms referred to. 

SODIUM SULPHATE.— Large 
amounts of a strong solution of this 
salt cause repeated alvine discharges, 
which finally consist chiefly of mu- 
cous fluid stained with bile. Serious 
poisoning with it is rare. 

SODIUM SULPHITE AND 
THIOSULPHATE.— Although large 
amounts of the sulphites have been 
taken by man without the production 
of poisoning, symptoms or irritation 
of the alimentary tract have been 
noted after even small doses. Some 
of the irritation of the stomach is as- 
cribed to the liberation of sulphurous 
acid by the hydrochloric acid of the 
gastric juice. 

THERAPEUTICS. — Gastrointes- 
tinal Disorders. — The alkaline salts of 
sodium, especially the bicarbonate, 
are used extensively in disorders of 
the alimentary canal. Given in the 
digestive period, the bicarbonate di- 
minishes the secretion of gastric 
juice, neutralizes some of the hydro- 
chloric acid, and acts as a carmina- 
tive by setting free carbon dioxide. 
Where organic acids are present, it 
may likewise neutralize them, and 
by doing so lead to the opening of a 
pylorus previously in spasm. 

In continuous gastric hyperacidity 
and in cases witli gastric fermenta- 
tion and resulting "sick headache," 
preparation of the stomach for a meal 
may be effected by giving a dose of 
sodium bicarbonate an hour before it. 
In the fermentation cases coml:)ina- 
tion of calomel with it may be ad- 
vantageous. For hyperchlorhydria 



manifesting itself after meals, the 
drug is also very eft'ective, and is 
beneficial, especially when taken one 
to two hours after the repast. A 
combination of sodium carbonate and 
magnesium oxide may be even more 
grateful, the latter compound exert- 
ing, in addition, a local sedative ef- 
fect. Where, however, stimulation of 
evacuation is particularly desired, an 
efl^ervescent mixture of sodium bi- 
carbonate, 30 grains (2 Gm.), with 
tartaric acid, 10 grains (0.6 Gm.) — 
dissolved separately in half a glass- 
ful of water, then mixed — is of value. 
Such a mixture may also prove 
useful in the vomiting attending 
acute inflammatory diseases and the 
exanthemata. 

The early morning acidity of hy- 
peracid cases may be prevented by 
the exhibition of a dose of sodium 
bicarbonate the night before. Mucus 
may be removed from the stomach, 
preparatory to breakfast, by a dose 
taken on arising. In alcoholic gas- 
tritis lavage with a dilute sodium bi- 
carbonate solution is useful for the 
same purpose. 

In gastric hyperacidity alkalies 
have two indications. They may be 
employed in the late pain of hyper- 
acidity, but the tendency of the pa- 
tient toward abuse of the drug must 
not be forgotten, for excessive use 
may cause gastritis. The author pre- 
fers bismuth subnitrate in large doses 
to the alkalies. The alkalies may 
also be employed to hasten the di- 
gestive process; here the so-called 
Vichy cure may likewise prove bene- 
ficial. The use of artificial Carlsbad 
salt seems, however, of greater 
value, the results being more last- 
ing. Hayem (Tribune med., xli, 281, 
1908). 

The prolonged suppression of salt 
in the diet reduces pain and vomiting 
in conditions of hyperacidity, while 



186 



SODIUM (SAJOUS). 



in other conditions in which the HCl 
is deficient the use of salt increases 
it and aids digestion greatly. The au- 
thor's experiments on a healthy man, 
following out L. Mcunicr's technique, 
showed that with certain foods, as 
meat, the digestion was the same 
with or without salt, but with other 
foods, such as milk, eggs, and car- 
bohydrate foodstuffs, the digestion 
was delayed from ten to twenty min- 
utes when no salt was given with 
them. Thus, in certain subjects and 
with certain foodstuffs, the addition 
of sodium chloride to the diet favors 
the gastric secretion. A. Martinet 
(Presse med., Apr. 1, 1908). 

In children, where an antacid is re- 
quired and constipation is present, 
sodium bicarbonate is preferable to 
lime-water. 

In yeasty vomiting, especially when 
sarcinse are present, sodium sulphite 
is often of value in doses of from 5 
to 20 grains (0.3 to 1.3 Gm.). The 
vomiting due to acid fermentation of 
starches and sugars may be relieved 
by the same salt in doses of from 20 
to 60 grains (1.3 to 4 Gm.), or by 
sulphurous acid, in doses of from 5 
to 60 minims (0.3 to 3.6 c.c), well 
diluted). 

In cases with dyspeptic pains asso- 
ciated with motor insufficiency, E. 
Binet recommends the use of two of 
the following powders at intervals, 
respectively, of one hour and half an 
hour before meals, and, if necessary, 
at the same intervals afer meals : — 

R Sodii bicarbonatis.. gr. xij (0.75 Gm.). 
Magnesii oxidi pon- 

derosi gr. iv (0.25 Gm.). 

Pulveris belladonH'CC 
folioruni gr. % (0.01 Gm.). 

Pone in chartulam no. j. 

Where there is pylorospasm due to 
hypersecretion, a powder should be 
taken one hour after the meal and re- 



peated at one and one-half-hour inter- 
vals until the next meal. 

In duodenal ulcer sodium bicar- 
bonate may give relief when the 
"hunger pain" appears. 

In catarrhal jaundice, sodium bicar- 
bonate, combined with rhubarb, has 
been considered especially useful. 
The official mixture of rhubarb and 
soda may be given. 

In chronic hepatic affections good 
results have at times followed the use 
of the solution of chlorinated soda, in 
doses of from ^ to 2 drams (2 to 8 
Gm.), diluted in from 4 to 8 ounces 
(120 to 240 c.c.) of water. . 

In constipation sodium sulphate is 
not as often employed as some other 
drugs in human beings, though 
largely used in veterinary practice, as 
it is one of the most irritant of the 
saline purges, producing large, watery 
stools with considerable griping. The 
purgative dose is from ^ to 1 ounce 
(7>4 to 30 Gm.). It should be used 
with some caution if any intestinal 
inflammation be present. It is one of 
the constituents of Carlsbad, Hun- 
yadi, and similar waters. According 
to Maberly, it frequently acts as an 
intestinal antiseptic in small doses. 

Sodium sulphate is an intestinal 
antiseptic. After observation of its 
action in dysentery and infantile di- 
arrhea, the writer relies almost en- 
tirely on it in all septic bowel 
complaints. To obtain the antiseptic 
action one must avoid doses having 
an aperient action. The dose should 
begin with about 6 grains (0.4 Gm.) 
for a baby under 6 months of age, 
increasing up to 1 dram (4 Gm.) for 
adults, given every six hours in one 
of the flavored waters, such as fen- 
nel. Children over 6 months old 
seldom exhibit any aperient effects 
from doses of 14 to 20 grains (0.9 to 
1.3 Gm.). The writer also uses the 
drug in typhoid fever; the stools, 



SODIUM (SAJOUS). 



187 



from being loose and fetid, become 
more normal in appearance and odor, 
and the temperature runs a lower 
course. Maberly (Lancet, Nov. 10, 
1906). 

For diuretic purposes, 4 Gm. (1 
dram) of sodium sulphate may be 
dissolved in 1 or V/2 liters (quarts) 
of v^rater, to be divided into three 
doses, one in the early morning, on 
a fasting stomach; one in the fore- 
noon, and one in the afternoon ; the 
water must be sipped slowly. For a 
light, non-irritating purgative effect, 
5 Gm. (V/i drams) of the salt may 
be dissolved in Yz or Y^ liter (quart) 
of water, to be divided in two doses, 
one in the early morning and one an 
hour before the noon meal; it should 
be taken warm. For an energetic 
purgative action, 25 to 60 Gm. (6 to 
15 drams) of sodium sulphate are to 
be dissolved in 200 c.c. (6 ounces) 
of water, sweetened if desired, or 
flavored with lemon, peppermint, or 
anise-seed, according to taste, to be 
taken at one dose. Alfred Martinet 
(Presse med., Aug. 23, 1911). 

Physiological salt solution passes 
through the gastrointestinal tract 
without irritating it or interfering 
with osmotic conditions. There is 
nothing which passes along so rap- 
idly. The writer has patients drink 
2 glassfuls of a 0.9 per cent, solution 
of sodium chloride twenty minutes 
before breakfast. After nine or 
twelve minutes defecation followed. 
The stomach expels the solution 
promptly, and reflexly sets up peris- 
talsis throughout the intestinal tract. 
The larger the amount ingested the 
more rapid the passage. Most min- 
eral waters are hypertonic and are 
absorbed in the duodenum unless 
large quantities are taken. After 
drinking the salt solution on an 
empty stomach in the morning the 
writer has the patient follow it with 
a cup of coffee or other appetizing 
drink. In atony of the stomach, the 
rapid expulsion of the physiological 
salt solution makes it a valuable reg- 
ulator of the bowels. Best (Med. 
Klinik, July 27, 1913). 



The use of sodium citrate has been 
strongly recommended in the treat- 
ment of digestive disorders, especially 
in children, as well as in acidosis and 
in pneumonia. According to Lacheny, 
15 grains (1 Gm.) of the salt allay 
dyspeptic pain in the stomach and 23 
grains (1.5 Gm.) promptly arrest most 
attacks of vomiting. 

The chief uses of sodium citrate 
in infant feeding are as follows: (1) 
for weaning the healthy infant; (2) 
for increasing the amount of milk 
taken in the twenty-four hours; (3) 
for correcting milk dyspepsia, and 
(4) for the avoidance of scurvy. It 
is not antibacterial. A good propor- 
tion is 1 grain (0.065 Gm.) of sodium 
citrate to the ounce (30 c.c.) of milk. 
Poynton (Brit. Med. Jour., Oct. 21, 
1905). 

Good results obtained from the use 
of sodium citrate added to milk in 
infant feeding when gastric disorders, 
especially vomiting, exist. When so- 
dium citrate is added to milk the 
coagulum is less solid and lighter. 
This is due to the fact that in the 
presence of sodium citrate the cal- 
cium salts, especially the chloride, 
which augment coagulation, are pre- 
cipitated. It is usual to administer 
1 to 2 Gm. (15 to 30 grains) a day 
to infants. Vomiting due to hypo- 
alimentation may derive as much 
benefit from its use as that due to 
superalimentation. The drug is su- 
perior to bicarbonate of sodium in 
digestive disturbances in adults, and 
does not cause a secondary secretion 
of acid in the stomach. Variot 
(Tribune med., Oct., 1910). 

Sodium citrate facilitates the diges- 
tion of milk when a milk diet is be- 
ing given, preventing the formation 
of large, compact clots where the 
fluid is drunk too quickly or in ex- 
cessive amounts at one time. Many 
cases of infantile dyspepsia yield 
when a tablespoonful of a 10-grain 
(0.65 Gm.) to the ounce (30 c.c.) 
solution of sodium citrate is added 



188 



SODIUM (SAJOUS). 



to each 4-ounce (120 c.c.) bottle of 
milk. 

Sodium citrate also acts as an al- 
kali, is soothing in pyrosis, dimin- 
ishes gaseous fermentation, and even 
obviates the regurgitation of food. 

Even in small doses, it is a good 
laxative. In constipation in dyspep- 
tics it lessens autointoxication and 
obviates mechanical disturbances. In 
constipation associated with hepatic 
congesion, Huchard frequently ad- 
vised its employment, along with 
sodium sulphate and bicarbonate: — 

IJ Sodii citratis, 

Sodii hicarhonatis, 

Sodii sulphatis.. . .aa. 3v (40 Gm.). 

M. Sig. : One teaspoonful every morn- 
ing in a hot infusion. 
Plicque (Bull, med., May 31, 1913). 

In certain conditions of malnutri- 
tion, marasmus, and chronic indiges- 
tion in infants and children, Le Bou- 
tillier and others have recommended 
subcutaneous injections of a dilute 
sea-water solution. 

In applying the sea-water treat- 
ment in infants, the writer followed 
the Robert-Simon method, diluting 83 
parts of sea-water with 190 parts of 
pure spring-water, filtering through 
a germ-proof Berkefeld filter, and 
putting it up in sterile bottles. The 
usual injection sites were just below 
the angle of the scapula or in the 
gluteal regions, the former being 
preferable. The amount injected 
varied from 10 to 60 c.c. (2>4 drams 
to 2 ounces), the usual dose being 
15 to 30 c.c. (^ to 1 ounce), accord- 
ing to age and urgency, and from 
three times a week to every day for 
a short time. Sometimes five or six 
injections improved the condition so 
much that the patient was discharged. 
In other cases the treatment had to 
be kept up for several months. There 
is improvement in the amount of food 
taken within the first two or three 
weeks; this is noticeable in older 
children suffering from malnutrition 
or chronic indigestion. In infants. 



distressing colic was invariably re- 
lieved within the first two weeks. 
The skin, often harsh, dry, and scaly, 
cleared up entirely, whether in in- 
fants or in older children. The pa- 
tients who were losing weight or 
stationary, as a rule, gained after the 
first few treatments, sometimes as 
much as an ounce a day. The sleep 
of many patients was markedly im- 
proved. The treatment is a useful 
adjunct of other methods in the mal- 
nutrition of tuberculous disease "t 
that following any of the infectious 
diseases, T. LeBoutillier (Jour. Amer. 
Med. Assoc, Jan. 1, 1910). 

In the cyclic vomiting of children, 
rectal or oral administration of a 2 
per cent, solution of sodium bicar- 
bonate is an essential measure where 
■ acidosis exists, in conjunction with 
the administration of dextrose, seda- 
tion of the vomiting reflex by means 
of drugs, and exhibition of fluids in 
copious amounts. 

In cancer of the stomach the use of 
sodium chlorate has, in some cases, 
been followed by good results. The 
initial dose recommended by Brissaud 
is 2 drams (8 Gm.) daily, in divided 
doses ; this is gradually increased un- 
til 4 drams (16 Gm.) are taken. If 
albuminuria be present or develop, 
the drug is contraindicated. 

In mercurial stomatitis, aphthae, 
mucous patches, and ulcers of the 
tonsils, sodium sulphite in 1 to 8 
solution may be applied with a cot- 
ton pledget, or in the form of spray. 

Calomenopoulo has emphasized the 
utility of sodium chlorate in mercurial 
stomatitis. He also noticed that so- 
dium chlorate in large doses reduced 
intolerance to potassium iodide where 
this drug was being taken in full 
doses for syphilis. 

Seatworms {Oxyuris vermicularis) 
may be dislodged from the rectum by 



SODIUM (SAJOUS). 



189 



injection of a solution of the chloride, 
and, with them, the intense itching. 
The injections should be given every 
morning, then every two to four 
evenings, with the buttocks ele- 
vated or in the Knee-chest posture 
until all evidence of the worms has 
disappeared. 

In dysentery the use of sodium ni- 
trate in dram (4 Gm.) doses, freely 
diluted, every three hours, has been 
recommended. 

Cutaneous Disorders. — In acute 
eczema, when there is much serous 
discharge, the following application 
is efficient: Sodium carbonate, ^ 
dram (2 Gm.) ; water, 1 pint (500 
c.c). The solution may be made 
stronger in old cases where the skin 
is much thickened. When the weep- 
ing has ceased and mere desquama- 
tion remains, the alkali ceases toi be 
of use. 

The pruritus of eczema, lichen, 
urticaria, dermatitis, burns, and frost- 
bite may be relieved by applications 
of the following: Sodium bicarbonate, 
3 drams (12 Gm.) ; glycerin and dis- 
tilled extract of witchhazel, of each, 
3 ounces (90 c.c). The itching of 
urticaria and lichen will often yield 
to a 1 : 100 solution of sodium car- 
bonate, applied with a sponge or 
mop. 

Poison-ivy eruption and other 
forms of pruritus may be similarly 
soothed by sodium hyposulphite in 
solution (1 to 16), a solution of the 
bicarbonate, or by the solution of 
chlorinated soda, diluted 1 to 32. 

In parasitic skin diseases, espe- 
cially those due to the tricophyton 
fungus, as pityriasis versicolor, the 
hyposulphite (1 to 8) in solution or 
ointment is valuable. Startin has 
recommended the following: Sodium 



hyposulphite, 3 ounces (90 Gm.) ; di- 
lute sulphurous acid, ^ ounce (15 
c.c.) ; water, enough to make 1 pint 
(500 c.c). In tinea versicolor and 
pruritus vulvae Fox found the follow- 
ing useful : Sodium hyposulphite, 4 
drams (16 Gm.) ; glycerin, 2 drams 
(8 Gm.) ; water, enough to make 6 
ounces (180 c.c). 

In scabies also the hyposulphite 
has been used successfully. After the 
morning bath apply the hyposulphite 
in solution (1 to 1) to the affected 
part and allow it to dry on the skin. 
At night bathe with the following 
lotion, which may be diluted if 
found too strong: Dilute hydrochloric 
acid, 4 ounces (120 c.c) ; distilled 
water, 6 ounces (180 c.c.) (Ohmann- 
Dumesnil). 

For the removal of freckles, sun- 
bum, and tan the following lotion 
may be used : Sodium chloride, 2 
drams (8 Gm.) ; potassium carbonate, 
3 drams (12 Gm.) ; rose-water, 8 
ounces (240 c.c.) ; orange-flower- 
water, 2 ounces (60 c.c). The in- 
flammation of sunburn may be sub- 
dued by applications of sodium bicar- 
bonate in solution. 

In hyperidrosis of the feet and 
axillae a solution of the carbonate 
freely applied locally will remove the 
fetor and diminish the secretion of 
sweat. 

In burns and scalds sodium bicar- 
bonate in powder or in solution re- 
lieves the pain and soreness very 
promptly. It may also be applied 
with advantage to insect bites. 

The carbonate is used externally 
when it is desirable to soften or re- 
move scaly or scabby accumulations 
upon the skin, as in certain forms of 
eczema, plica polonica, etc. 

In tuberculous ulcers and in psoria- 



190 



SODIUM (SAJOUS). 



sis, g^ood results have at times been 
secured with hypodermic injections 
of diluted sca-ivatcr, as orijuinally 
su.G^n;-ested by Robert-Simon and 
Quinton. 

Genitourinary Disorders. — Irrita- 
tion of the urinary })assa£;;"es due to 
an excess of acid may be allayed by 
sodium bicarbonate in doses of 10 to 
20 g-rains (0.6 to 1.3 Gm.), given in 
a glass of water, every four hours. 

In cystitis a 1 per cent, solution of 
the bicarbonate may be used to wash 
out the bladder when an acid condi- 
tion of that viscus exists. 

Some relief is afforded in gonorrhea 
by injections of a 1 per cent, solution 
of the bicarbonate. 

In malarial hematuria sodium hy- 
posulphite is given with advantage in 
doses of from 10 to 30 grains (0.6 to 
2.0 Gm.), every four hours. Its mode 
of action is unknown. 

Fischer's solution, containing 10 
Gm. (150 grains) of sodium car- 
bonate (crystallized) and 14 Gm. (210 
grains) of sodium chloride to the liter 
(quart) of water, has been used in- 
travenously in amounts up to 2 liters 
(quarts) for the relief of anuria in 
scarlet fever, eclampsia, Asiatic chol- 
era, etc. In less urgent cases of im- 
paired renal function, including cases 
of chronic nephritis, the sodium bicar- 
bonate may be increased to 15 to 30 
Gm. (225 to 450 grains) in the liter, 
and the solution given per rectum by 
the drop method. 

Sodium chloride having long been 
known as a powerful diuretic, the 
writer used it as a last resort in ad- 
vanced nephritis, and obtained striking 
benefit after a prolonged period on a 
salt-free diet. When no benefit fol- 
lows the salt-free diet, a single large 
amount of sodium chloride, 1 to 3 
days during the week, may induce 



marked diuresis and considerable clin- 
ical improvcnunt. Polag (Schweizer. 
mcd. Woch., i, 29, 1920). 

Laryngologic and Respiratory Dis- 
orders. — In asthma the use of potas- 
sium nitrate in 3- or 4- grain (0.2 or 
0.26 Gm.) doses has been highly 
commended. The drug is probably, 
in part, changed to a nitrite in the 
system, and acts as such. 

In pulmonary hemorrhage the ad- 
ministration of dry salt is a popular 
remedy. 

Use of salt by the mouth or in 
infusion recommended to control 
hemorrhage. Salt enhances the co- 
agulating power of the blood in the 
living subject, though not in the test- 
tube. This may be due to the mobi- 
lization of thrombokinase stored up 
in the tissues. In 29 cases of hem- 
optysis the writer obtained excellent 
results by giving 75 grains (5 Gm.) 
of sodium chloride by the mouth, 
coagulability being much increased 
thereby for an hour to an hour and 
a half. The effects become evident 
in a few minutes. If the tendency 
to hemorrhage returns later, the dose 
of salt is repeated, or potassium bro- 
mide substituted in the dose of 45 
grains (3 Gm.), the bromide having, 
further, a sedative action. In the most 
urgent cases the use of sodium chlo- 
ride and potassium bromide, in full 
doses, may be combined. R. von den 
Velden (Deut. med. Woch., Feb. 4, 
1909). 

In capillary hemorrhages, including 
capillary hemoptysis, in the hemor- 
rhagic diathesis, and in epistaxis and 
metrorrhagia, Reverdin claims 2-grain 
(0.13 Gm.) doses of sodium sulphate 
every hour to be of great value. The 
drug must be given by mouth or 
intravenously, not hypodermically. 
It is believed by him to increase the 
coagulabilitv of the blood. 

In acute tonsillitis, catarrhal condi- 
tions, bronchitis, etc., sodium l)icar- 



SODIUM (SAJOUS). 191 

bonate in solution may be combined Solutions of sodium bicarbonate are 

with hamamelis, belladonna, or other extensively used in catarrhal condi- 

remedial agent. According to Bulk- tions to soften and remove dried 

ley, coryza may be successfully secretions and thickened mucus. Do- 

treated by giving 20 to 30 grains bclVs solution (sodium bicarbonate and 

(1.3 to 2 Gm.) of the sodium bicar- borax, of each, 2 drams — 8 Gm. ; 

bonate in 2 or 3 ounces (60 or 90 c.c.) phenol, 24 grains — 1.5 Gm. ; glycerin, 

of water, every half-hour, for three 14 drams — 56 Gm. ; water, 1 pint — 

doses, with a fourth dose an hour 500 c.c.) is largely used for this pur- 

from the last one. Two to four pose. Pynchon has recommended the 

hours are next allowed to elapse, and following as better : Sodium bicar- 

the four doses are then repeated if bonate and borax, of each, 2 ounces 

there seems to be necessity, as is fre- (60 Gm.) ; listerin (liquor antisepti- 

quently the case. After waiting two cus, U. S. P.), 8 ounces (240 c.c); 

to four hours more the same course glycerin, 1^ pints (750 c.c.) ; of this 

may be taken again. To be promptly add 1 ounce (30 Gm.) to 1 pint (500 

effective the measure should be begun c.c.) of water. 

with the earliest indications of coryza Gynecological and Puerperal Disor- 

and sneezing, when it rarely fails to ders. — Leucorrhea, when dependent 

break up the cold. upon an increased secretion of the 

K. E. Kellogg points out that in cervical glands, frequently yields to 

hay fever marked relief from the injections of a 1 per cent, solution of 

rhinitis symptoms follows the taking the bicarbonate. This secretion is 

of sodium bicarbonate in 1-dram (4 strongly alkaline, and is checked on 

Gm.) doses three times a day. The the general principle that alkalies 

drug appears to have a desensitizing check alkaline secretions. 

action on the mucous membranes. In puerperal metritis the solution 

In a few cases he found it necessary of chlorinated soda (1 part to 10 or 

to supplement the treatment with a 12 of water) has been used as an 

nasal spray of sodium bicarbonate antiseptic injection. In the same 

solution. strength it may be used as a vaginal 

In affections of the throat and douche when the lochial discharge 

fauces, sodium chlorate is a better becomes fetid. It is also a useful 

and safer remedy than the potassium injection in simple and gonorrheal 

salt. vaginitis. 

In malignant forms of sore throat A hypertonic solution of 4 drams 

and in diphtheria the official solution (16 Gm.) of sodium chloride and >4 

^r ^1,1^,-;,,^+ A A^ rj/ A. o j^^^„ dram. (2 Gm.) of sodium citrate to 

of chlormated soda (% to 2 drams — , . .r^r. n r i 

_ ^ ^ . . r. the pint (500 c.c.) of water proved 

2 to 8 Gm.—m water, 4 to 8 ounces— ^^^ effective vaginal douche in all 

120 to 240 c.c.) has been used as a inflammatory diseases of women and 

gargle. Sodium sulphite in solutiotl in septic conditions, giving better 

(1 to 8) may be used as a gargle, results than the customary antiseptic 

spray, or local application in similar douches. In infected puerperal le- 

... T , , , 1 • sions of the genital tract healthy 

conditions. It has also been used in- , ^. „ ^^^„^^a ;„ -, f«,„ 

granulation was secured in a tew 

ternally in combination with sulphur ^ays. After clearing out the uterus 

and calomel. in puerperal sepsis and douching it 



192 



SODIUM (SAJOUS). 



with the hypertonic saline solution, 
a few tablets of salt left in the uter- 
ine cavity cause the flooding of any 
remaining organisms with the serum 
drawn out to dissolve the salt and 
materially hasten recovery. All con- 
ditions producing pelvic congestion 
responded well to the hypertonic 
douches. Enemata of water contain- 
ing from 3 to 6 or 8 drams (12 to 24 
or 32 Gm.) of salt to the pint (500 
c.c.) proved effective in emptying 
the bowel in eclampsia and other 
conditions requiring a watery evacu- 
ation for the removal of toxic ma- 
terial. Clifford White (Lancet, Oct. 
30, 1915). 

Constitutional Disorders. — Acute 
rheumatism, though usually best 
treated with the salicylates (see 
Salicylic Acid), is also amenable to 
the action of the alkalies. Sodium 
bicarbonate is of great service in 
allaying the pain and soreness of the 
joints when given internally in doses 
of from 15 to 30 grains (1 to 2 Gm.) 
every four hours. It may also be 
used in solution as a lotion, applied 
around the joints on lint or cloths. 
Sodium nitrate in solution (1 to 3) 
has been used externally in like man- 
ner. Sodium acetate has been given 
in acute rehumatism and gout, but its 
value is less than that of the corre- 
sponding potassium salt. 

In conditions associated with acido- 
sis, including diabetes mellitus, so- 
dium bicarbonate or carbonate have 
been extensively used. To act as a 
blood alkalinizer sodium bicarbonate 
should be given shortly before meals, 
when no acid to neutralize it is pres- 
ent in the stomach. In diabetic coma, 
delayed chloroform poisoning, and 
similar severe states of acidosis, doses 
as large as ^ ounce (15 Gm.) of 
the bicarbonate have been given by 
mouth, or by the rectal drop method, 



amounts up to 1% ounces (50 Gm.) 
a day, in a 3 per cent, solution in 
water. At times, gratifying results 
have been obtained. 

Sodium citrate advocated in place 
of sodium bicarbonate for use in 
acidosis. It is practically tasteless, 
and may be added to the food or 
given in water and lemon-juice. Al- 
though the author has given as much 
as l}/2 ounces (45 Gm.) a day, it 
causes much less digestive disturb- 
ance than the bicarbonate, and diar- 
rhea never followed its administra- 
tion. Lichtwitz (Therap. Monat., 
XXV, nu. 81, 1911). 

The hypodermic use of sodium bi- 
carbonate solutions has fallen into 
disrepute on account of their ex- 
tremely irritating properties. This is 
because during sterilization this salt 
is largely converted into sodium car- 
bonate. The latter may be recon- 
verted into sodium bicarbonate if 
carbonic acid gas is allowed to 
bubble through the sterilized solu- 
tion. The latter is then well borne 
both subcutaneously and intraven- 
ously, and is indicated in diabetic 
coma. A 4 per cent, solution should 
be used. The writer advocates the 
preparation of such solutions in 
sealed flasks with a carbonic acid 
atmosphere. Magnus-Levy (Med. 
Klinik, S. 2001, 1914). 

Vorschiitz has called attention to 
the value of an alkali in whipping up 
the body cells to proper metabolism 
and elaboration of protective sub- 
stances. A deficiency of alkali, he 
asserts, may be responsible for defec- 
tive antibody production. In cases 
with severe septic processes, osteo- 
myelitis, scarlatinal nephritis with 
abscess, etc., he witnessed good ef- 
fects from having the patients drink 
during the day a bottle of Seltzer- 
water, in which 150 to 300 grains (10 
to 20 Gm.) of sodium bicarbonate had 
been dissolved. Although in some 



SODIUM (SAJOUS). 



193 



cases gastric discomfort necessitated 
at times svispension of the treatment 
for a day or two, some patients took 
the doses mentioned for weeks with- 
out disturbance, and all cases thus 
treated recovered. 

Surgical Disorders. — In fractures 
and sprains a solution of sodium sili- 
cate constitutes a valuable dressing, 
as it rapidly becomes hard and im- 
movable when painted over the band- 
ages and thus forms an immovable 
splint which is cleaner than plaster 
of Paris and equally effective. 

Morbid growths, warts, etc., may 
be removed by applications of caustic 
soda or of London paste. 

Wright's solution, composed of 4 
per cent, sodium chloride and 1 per 
cent, sodium citrate in water, is 
useful in the treatment of infected 



cold more of the hot solution is 
poured over the whole dressing. The 
solution is contraindicated if there is 
a tendency to persistent oozing of 
blood from the wound, and when 
protective adhesions are desirable, as 
in certain abdominal wounds just 
after operation. The solution should 
be used only for the first thirty-six 
to seventy-two hours after operation, 
during the acute stage of the mflam- 
mation. If used longer it leads to 
maceration and indolence in healing. 
L. R. G. Crandon (Annals of Surg., 
Oct., 1910). 

Wright's citrated isotonic solution 
(sodium citrate, 0.5; sodium chloride, 
3.0; distilled water, 100) used with 
great satisfaction in the treatment 
of wounds. G. K. Dickinson (Med. 
Rec, June 20, 1914). 

Foul ulcers, sinuses, etc., may be 
cleansed with liquor sodse chlorinatae, 
diluted in the proportion of ^ to 4 



wounds, abscesses, etc. The citrate, drams (2 to 16 c.c.) to 8 ounces (250 
by precipitating the calcium salts in c.c.) of water. In military practice 
the lymph, prevents coagulation and a 3^ per cent, solution of sodium hy- 
insures free exit of lymph discharge, pochlorite has been extensively used 
The chloride, in hypertonic solution, for checking infection in wounds, 
hastens the flow of lymph by osmosis, Dakin's solution is prepared by dis- 
thus antagonizing bacterial develop- solving, in 10 liters (quarts) of tap- 
ment, and is itself antiseptic owing to water, 140 Gm. (4^^ ounces) of dried 
its hypertonicity. sodium carbonate (or 400 Gm. — 13 

In using Wright's solution for ounces — of the crystalline salt) and 
drainage, the abscess is opened by a 200 Gm. (6% ounces) of good quality 

calcium chloride. The mixture is well 
shaken up and after half an hour the 
clear liquid separated by siphonage, 
filtered through cotton, and 40 Gm. 
(1% ounces) of boric acid added. In 
Carrel's technique of wound treat- 
ment, rubber tubes surrounded by an 
absorbent, spongy material are car- 
ried to the bottom of the wound and 
in each of its recesses, and Dakin's 
solution is injected into the tubes at 
one or two-hour intervals, or, better, 
introduced by continuous instillation 
by the drop method. 



wound as small as will allow the 
cavity to be wiped out, or thor- 
oughly emptied by expression. The 
surrounding skin is thoroughly 
cleaned with 70 per cent, alcohol 
and smeared with boric acid or 
eucalyptus petrolatum. If the skin 
tension closes the lips of the wound 
a bit of rubber dam may be put in. 
The wound is covered with a large 
pad of gauze or of absorbent cotton 
covered with gauze, dripping wet 
with hot salt and sodium citrate 
solution. The part is put at rest. 
* Outside the dressing may Ijc applied 
a hot flaxseed poultice or a hot-water 
bottle. As often as the dressing gets 



8—13 



194 



SODIUM (SAJOUS). 



Intravenous infusion of 3 to 5 c.c. 
(48 to 80 minims) of a 5 per cent, 
salt solution practised with the best 
results before operations in which 
parenchymatous hemorrhage is feared 
or when the blood coagulates less 
readily than normal. The measure 
is advised in prophylaxis or during 
the operation, repeating it every half- 
hour as needed. Von den Velden 
(Zentralbl. f. Chir., May 21, 1910). 

Instruments, especially if plated, 
when boiled in a solution of sodium 
carbonate or bicarbonate come out 
covered with a white scum, are slip- 
pery, and less quickly dried, and are 
likely to turn black, especially if they 
have any blood left on them. The 
writer recommends, instead, the use 
of sodium hydroxide, which has not 
these disadvantages. About 38 grains 
(2.5 Gm.) or Y^ inch of stick caustic 
to a quart (liter) of water makes the 
proper solution. I. M. Ileller (Jour. 
Amer. Med. Assoc, Aug. 26, 1911). 

CHLORIDES IN URINE.— These con- 
sist chiefly of sodium chloride, with a 
small amount of potassium and ammonium 
chlorides. The healthy adult excretes 
from 10 to 16 grams of chlorides in 24 
hours. The chlorides are increased nor- 
mally, by increased ingestion of salt, by 
al^undant drinking of water, and by active 
exercise; abnormally, in the first few days 
after the crisis of acute febrile diseases, 
gradually increasing as the disease abates; 
in diabetes insipidus; in dropsy after 
diuresis has set in. The chlorides are 
decreased normally during repose; abnor- 
mally, in all acute febrile conditions (espe- 
cially with serous exudations) up to the 
crisis, when they may disappear; in pneu- 
moniia their absence always indicates a 
serious condition; in diarrhea; in chronic 
conditions with impaired digestion and 
dropsy; during the formation of large exu- 
dations; in acute and chronic diseases of 
the kidnej'S with albuminuria; in chronic 
diseases. A decided diminution or ab- 
sence of chlorides in a febrile condition 
strongly suggests pneumonia. 

Test for Chlorides. — Place 2 drams of 
urine in a test-tube, acidify with 10 or 12 
drops of nitric acid, C. P., and carefully 
add 1 drop of silver nitrate solution 



(1 to 8). If the amount of chlorides be 
about normal, this drop will form a whit- 
ish globule, a solid white ring or one or 
more compact, whitish, flocculent lumps, 
and will settle to the bottom. If the chlo- 
rides are diminished, there will be only 
some cloudiness. (Jne may use a speci- 
men of normal urine in another test-tube 
as control. When the exact quantity of 
chlorides is desired, one must resort to 
quantitative titration, the technique of 
which may be found in larger treatises on 
Uranalysis. 

SALINE SOLUTION.— Prepara- 
tion. — As ordinarily prepared, "nor- 
mal" saline solution is of 0.8 to 0.9 
per cent, strength. For the prepara- 
tion of a sterile solution of this type, 
sterile sodium chloride may be dis- 
solved in sterile water in the ratio of 
1 dram (4 Gm.) of the salt to 1 pint 
(roughly 500 c.c.) of water; or, the 
solution may be sterilized after the 
salt has been dissolved. The solution 
should then be filtered into flasks, and 
these plugged with non-absorbent cot- 
ton and sterilized in toto. 

Hypertonic sodium chloride solu- 
tions are at times used, as in the 
hypertonic saline treatment of Asiatic 
cholera devised by Rogers, in which 
1.2 or 1.6 per cent, solutions of the 
salt are employed. (See Cholera.) 

Physiological Action and Uses. — 
Introduction of normal saline solu- 
tion into the system may be of value 
in a variety of ways. In hemorrhage 
and in depleted states, such as that 
arising in cholera, it is of assistance 
to restore the blood volume to nor- 
mal, thereby not only favoring better 
distribution of blood to the periph- 
eral parts of the body, but also im- 
proving heart action by allowing the 
organ to contract under more normal 
mechanical conditions. In toxe.mic 
states, saline solution is of value to 
promote renal activity and therewith 



SODIUM (SAJOUS). 



195 



elimination of toxic material. Where 
the blood-pressure is low, a small sa- 
line infusion containing a moderate 
amount of epinephrin is of great 
value, though unless the administra- 
tion be continued the effect soon 
wears off through filtration of the 
solution from the vessels into the tis- 
sues. (Large saline infusions under 
these conditions merely favor the pro- 
duction of edema.) Saline infusions 
are also of value for the relief of 
thirst. 

Absorption of saline solution, how- 
ever given, is generally rapid. In 
saline hypodermoclysis a pint of solu- 
tion may be absorbed within ten or 
fifteen minutes, though at times 
marked circulatory weakness greatly 
delays the process. After hemor- 
rhage, especially rapid absorption oc- 
curs from the bowel. 

Modes of Administration. — Among 
the various routes available are: (1) 
the rectal ; (2) the subcutaneous ; (3) 
the intravenous ; and (4) the intra- 
peritoneal. 

(1) Saline enteroclysis (proctocly- 
sis ; rectal infusion) is advantageous 
in that the slight pain entailed in the 
insertion of a needle through the skin 
is avoided, and that the use of a sterile 
solution is not necessary. The older 
method of applying the procedure 
consists merely in passing into the 
rectum a pint to a quart of saline solu- 
tion at 110° F. through a small cathe- 
ter, twenty to thirty minutes being al- 
lowed for its entrance into the bowel. 
The measure may be repeated at four- 
hour intervals as long as the necessity 
for saline administration persists. An 
improved procedure is that recom- 
mended by John B. Murphy, in which 
precise adjustment of the flow of 
saline solution to the absorptive 



power of the bowel is sought. An 
excellent description of Murphy's 
technique of proctoclysis, kindly 
furnished us bv Dr. Richard L. 
Stoddard, of Rochester, N. Y., is 
subjoined : — 

Cleansing enemas, to the extent of emp- 
tying the intestinal tract of fecal matter, 
are necessary before beginning the proc- 
toclysis treatment. Thorough elimination 
of all formed feces from the intestinal 
tract during the preoperative preparation 
is of paramount importance. 

The saline solution is made by adding 
1 dram (4 Gm.) each of sodium chloride 
and calcium chloride to each pint (500 c.c) 
of hot water. The solution must be main- 
tained at a temperature per rectum of 100° 
to 110° F. 

The average quantity is \y2 to 2 pint3 
(250 to 1000 c.c.) every two hours. The 
quantity to be given depends upon the 
severity of the case, the age of the pa- 
tient, and the development of an edema. 
The average twenty-four-hour quantity is 
18 pints. In a child of 11 years (a patient 
of Dr. Murphy's) 30 pints were adminis- 
tered in twenty-four hours. Murphy 
states that "less than 8 pints in twenty- 
four hours is of very little value from a 
therapeutic standpoint." 

The base of the saline solution container 
should be elevated sufficiently — 2, 4, or 6 
inches — above the buttocks of the patient 
to allow 1^ to 2 pints of the solution to 
flow into the rectum in from forty to sixty 
minutes. The rapidity of the tlow should 
never be controlled by the use of forceps, 
clamps, knots, or faucets, in connection 
with the tubing. The height of the con- 
tainer must always control the hydrostatic 
pressure, which should average 4 to 6 
inches, and not exceed 15 inches. 

The patient is placed in the Fowler 
position, and the proctoclysis continued 
for two or three days, and sometimes five 
or six days. Too much solution after the 
third, fourth, or fifth day is indicated by 
edema of the ankles, hands, and even the 
face, and occasionally i)y threatened heart- 
failure. The solution should then be dis- 
continued until the circulatory equilibrium 
is restored, when the treatment may be 



196 



SODIUM (SAJOUS). 



repeated if indicated. The Fowler posi- 
tion, being uncomfortable for many pa- 
tients, need be used only in exceptional 
cases where abdominal drainage is neces- 
sary for twenty-four to forty-eighth hourg. 
An excellent and comfortable substitute 
for the Fowler position is to raise the 
head of the bed 12 to 18 inches. 

A medium-sized hard-rubber vaginal 
douche tube, with several %- to %-inch 
openings, makes a useful rectal tube, 
which must be flexed at an obtuse angle 
2 or 3 inches from its tip. The rectal 
tube will cause no inconvenience if so 
strapped to the thigh as not to press on 
the posterior wall of the rectum. Fre- 
quent changing of the rectal tube, as re- 
moving and inserting, or an improper posi- 
tion of the tube, or a too rapid flow of 
the solution into the rectum, are each and 
all very annoying to the patient, and soon 
produce an irritation of both the anus and 
rectum, resulting in partial or complete 
evacuation of the saline solution. 

When the patient strains during the act 
or vomiting, coughing, or sneezing, or 
wishes to expel gas or fluid, provision 
should always be made for a sudden re- 
turn of the fluid through the rectal tube 
and rubber tubing into the saline solution. 
For this important purpose, one should 
use a medium-sized rectal tube with the 
openings as described; avoid attempting 
to control or govern the rapidity of the 
flow by the use of clamps or faucets, 
and also avoid overdoing the hydrostatic 
pressure. 

If the rectum is not in an irritated con- 
dition from surgical interference, or other- 
wise, success in the early administration 
of large quantities of saline solution will 
be had with the above technique. 

In case an elaborate and electrically 
heated solution container is not at hand, 
an ordinary douche-can may be employed, 
and may be maintained at the desired 
temperature by first immersing a bath 
thermometer in the saline solution, and 
then surrounding the container with bot- 
tles filled with boiling water, or immersing 
one or two bottles in the solution. To 
further retain the heat, the whole ap- 
paratus, bottles and container, may be 
wrapped in a warm woolen blanket. By 
immersing a 16-candle-power electric-light 



globe and a thermometer in the saline 
solution, the desired temperature can be 
more easily maintained. 

For the past three years Dr. Stod- 
dard has been using the Ny lander 
electric saline heater, which correctly 
regulates the temperature. He has 
thoroughly tested the Murphy method 
of proctoclysis in peritonitis, typhoid, 
uremia, diphtheria, pneumonia, shock 
from hemorrhage, and local and gen- 
eral septicemia, and has found it of 
inestimable value, especially if used 
early and before the heart has been 
badly affected by the intoxication. 

In lobar pneumonia proctoclysis 
with hot tap-water was usually fol- 
lowed in a few hours by abatement 
of the signs of toxemia and mental 
improvement. In typhoid fever bene- 
fit was also noted. In obstinate cases 
of delirium tremens the mental state 
rapidly cleared up. In 4 cases of 
scarlet fever, 2 very severe, excellent 
results were obtained. The casts and 
albumin found in the urine early in 
the disease disappeared before the 
patients left their beds. In the inter- 
current febrile, "grippal" attacks of 
pulmonary tuberculosis, the comfort 
of the patient was greatly increased 
and the invasion apparently cut short. 
In the sudden flooding of the sys- 
tem with toxins from confined pus 
which not rarely occurs in tuber- 
culous subjects, remarkable ameliora- 
tion of the symptoms may follow 
saline proctoclysis. Henry Sewall 
(Amer. Jour. Med. Sci., Oct., 1910). 

All patients show less rectal irrita- 
tion to proctoclj'sis if given a saline 
enema before the operation. Patients 
given water by rectum absorb nearly 
400 c.c. more in the twenty-four 
hours than do patients given salt 
solution, the average for the former 
being 2444 c.c, and for the latter 
2041 c.c. Patients given salt solution 
by rectum require nearly twice as 
much water by mouth to relieve 
thirst — 696 c.c. in the first twenty- 
four hours, as against 332 c.c. The 



SODIUM (SAJOUS). 



197 



amount of urine is practically the 
same in the two classes of cases. In 
drainage cases more fluid may be 
taken by rectum than in laparotomies 
closed without drainage. Proctocly- 
sis should be employed more fre- 
quently, and in all classes of cases 
in which it is possible. Care should 
be taken to prevent "water-logging" 
of the system, this applying to both 
salt and water. In peritonitis cases 
with drainage, the patient can take 
four or five times as much fluid by 
rectum as in other conditions. H. H. 
Trout (Jour. Amer. Med. Assoc, 
May 4, 1912). 

A new device which consists in 
placing a two-quart heating bag near 
the patient's rectum, through which 
the salt solution pipe passes as in a 
hot-water bath, prevents the great 
loss of heat from the tube, as in 
other methods. In this method the 
temperature of the saline as it enters 
the rectum at first, when the heating 
bag has just been filled, is about 108° 
F., from which it drops gradually in 
an hour and a half to 98°, when the 
heating bag is refilled at 140° F. and 
the rectal temperature returns to 
108° F. G. H. Tuttle (Inter. Jour, of 
Surg., June, 1913). 

Proctoclysis method applied to in- 
fants in place of subcutaneous saline 
injection. Tolerance was perfect, 
even in the youngest. Fifty or 100 
c.c. of isotonic saline solution or 4 
per cent, solution of sugar is ab- 
sorbed as rapidly as by subcutaneous 
injection. Excellent results obtained 
in children of all ages with gastro- 
enteritis, cyclic vomiting, acute ali- 
mentary anaphylaxis, and typhoid 
fever. In some cases a little epi- 
nephrin was added. The latter was 
more effectual by rectum than by 
mouth. Lesne (Bull, de la Soc. de 
Pediat., Oct., 1913). 

Saline proctoclysis by the drop 
method gives in typhoid fever results 
as good as, if not superior to, those 
of the cold-bath treatment. In the 
lung complications of typhoid fever, 
dyspnea is relieved and the physical 



signs of lung condensation caused to 
disappear by the measure. Even in 
acute, frank pneumonia, the proced- 
ure at once reduces the dyspnea and 
liquefies the secretions. The heart is 
quieted, marked diuresis supervenes, 
and the crisis ordinarily occurs on 
the fifth day, though the physical 
signs persist a few days longer. P. 
E. Weil (Presse med., Feb. 14, 1916). 

(2) Saline hypodermoclysis (sub- 
cutaneous infusion), while usually 
highly efficient, is somewhat painful. 
Careful asepsis is required, and care 
must be taken not to introduce too 
much sokition in a single area, lest 
the prolonged anemia of the tissues 
lesuh in their devitalization and 
sloughing. The method is especially 
indicated where the emergency is not 
such as to require intravenous infu- 
sion but the rectal route is unavail- 
able because the bowel is too irritable 
or for some other reason. 

Hypodermoclysis may be practised un- 
der the breast, in the loose tissue over the 
pectoral muscle, on the posterior or inner 
aspects of the thighs, beneath the ab- 
dominal skin, including the iliolumbar 
regions, or between the scapulae. The 
reservoir for the solution is usually of 
glass, preferably graduated. The needle 
should be long and preferably of a large 
caliber, such as 1 to 2 millimeters, for 
although a small hypodermic needle may 
be successfully used, greater hydrostatic 
pressure is then required and the solution 
cools more as it descends through the 
tube, necessitating an original tempera- 
ture of 110° C, as against 105° C. if the 
aspirating needle is used. The entire ap- 
paratus should have been sterilized. Be- 
fore the infusion is given, the breast, in 
the case of women, is carefully disin- 
fected. It is then raised, and the needle, 
with the fluid flowing from it, gently in- 
serted into the cellular tissue beneath the 
organ. The pain of the puncture may be 
avoided with ethyl chloride. Where ele- 
vation of the reservoir is insufificient to 
maintain the flow, or the latter stops some 



1 98 



SODIUM (SAJOUS). 



time after, withdrawing the needle slightly 
or rotating it will usually start the stream 
again. If not, the fluid can be forced in 
by anointing one hand and the tube with 
petrolatum, and stripping the tube down- 
ward between the lingsers. Seven hundred 
cubic centimeters of fluid (lyi pints) can 
be injected under each breast. After com- 
pletion of the procedure the puncture can 
be closed with rubber tissue or adhesive 
plaster. 

Absorption from hypodermoclysis where 
the general circulation is markedly im- 
paired can be hastened by the addition, 
where possible, of enteroclysis, or even a 
simple hot saline enema (R. C. Kemp). 
Gentle local massage also hastens it. 

Salt solution for therapeutic pur- 
poses may be injected into the pre- 
vesical space of Retzius. This space 
is roomy, the connective tissue is 
loose, and can easily hold one liter 
(quart) of solution. The needle is 
inserted just above the symphysis 
pubis, and pushed along the rear wall 
of the latter. In a large experience, 
puncture of the bladder never oc- 
curred. The author uses a fairly 
large needle. One is thus able to 
inject a liter of solution in eight to 
nine minutes. D. Schoute (Zentralbl. 
f. Chir., July 6, 1912). 

For hypodermoclysis the writer 
uses a large silver cannula from a 
Southey tube apparatus, connected 
with a large glass funnnel by means 
of a tapered glass tube and a section 
of Southey's rubber tubing. This is 
all readily portable and readily ster- 
ilized by boiling. In administering 
the saline the anterior axillary fold 
is grasped firmly and drawn out- 
ward. The trocar with cannula is 
then passed into the skin in a direc- 
tion perpendicular to the chest and 
pushed through the axillary fold, so 
that its point emerges within the 
■ axilla. The trocar is then removed 
and the cannula is pushed outward 
until its shoulder is flush with the 
skin. The fluid emerging from this 
cannula squirts in all directions. It 
is absorbed so rapidly that one can 
inject a quart into the tissues in 



twenty minutes without any material 
swelling occurring. E. M. Wood- 
man (Brit. Med. Jour., Feb. 8, 1913). 

(3) Intravenous saline infusion is 
indicated in the more urgent emer- 
gencies, e. g., after very abundant 
hemorrhage; in cases of shock; where 
prompt elimination of toxic material 
from the blood is desired, as in de- 
lirium tremens, gas poisoning, and 
septicemia, and where anuria has de- 
veloped, the rise in blood-pressure 
attending intravenous infusion caus- 
ing a resumption of renal function. 

The apparatus required comprises some 
.species of graduated reservoir for the 
saline solution, a connecting rubber tube 
with pinchcock, and a cannula for inser- 
tion into the vessel. A slightly curved 
cannula is to be preferred, facilitating 
maintenance in the lumen of the vessel. 
In emergencies the glass portion of a 
medicine dropper may be substituted. As 
in hypodermoclysis, the apparatus and 
solution used should be sterile. The nor- 
mal saline solution should be placed in 
the reservoir at a temperature of 120° F. 
Another useful form of apparatus com- 
prises a large flask, arranged like the ordi- 
nary wash bottle, with two glass tubes, 
one short and the other long, entering it 
through the stopper. The longer glass 
tube, dipping into the contained saline 
solution, is connected by tubing with the 
infusion cannula, while to the other tube 
a rubber pressure bulb is attached. Pres- 
sure upon this bulb forces air into the 
flask, and hence the saline solution into 
the vein. The temperature of the solution 
in the flask may be maintained by placing 
it in a large jar partly filled with hot 
water. 

Preparation of the patient consists in 
placing a constricting bandage around the 
upper arm, tightly enough to obstruct the 
venous return flow, thus distending and 
rendering easily visible the vein to be 
employed, usually the median basilic or 
median cephalic at the bend of the elbow, 
applying alcohol or tincture of iodine at 
the latter area, and exposing the vein, 
under aseptic precautions, for a distance 



SODIUM (SAJOUS). 



199 



of about one inch. After passing two 
ligatures, untied, round the vessel, a small 
valve-shaped opening, the flap of vessel 
raised pointing distally, is made v^^ith 
pointed scissors, and the cannula, well 
filled with solution and free of air-bubbles, 
passed into the opening. The cannula is 
now fixed in the vessel by tying the upper 
ligature, the low ligature also tied to close 
the vein below, and the constricting band 
round the arm removed. The saline solu- 
tion receptacle should be at such an alti- 
tude, usually about three feet, above the 
vein that the solution will run in but 
slowly. The heart and blood-pressure 
should be watched, care being taken not 
to dilate and weaken the former or to 
raise the latter excessively by infusing 
too much solution. The usual amount is 
1 to 3 pints (500 to 1500 c.c). In shock 
injection of 1:1000 epinephrin solution 
with a hypodermic syringe into the lumen 
of the rubber connecting tube may be ad- 
vantageous. This should be done slowly, 
a few drops being given every few min- 
utes until the desired rise in blood-pres- 
sure has been obtained. Another good 
procedure is to drop the epinephrin, ac- 
cording to requirements, in a funnel into 
which the saline solution is being poured 
at intervals as it is consumed. 

Many users of intravenous saline ther- 
apy simplify the insertion of the needle 
by dispensing with exposure of the vein, 
the needle, with an obtuse angle point, 
being merely thrust obliquely into the 
distended vessel while the solution is flow- 
ing. The point of the needle should not 
be too sharp, to avoid inadvertent injury 
to the vessel's walls after its insertion, 
and should be held firmly in proper rela- 
tion to the vein while the saline solution 
is being run in. 

(4) Intraperitoneal saline infusion 
is of value at the termination of 
abdominal operations attended with 
marked shock, provided extension of 
an intra-abdominal infection as a re- 
sult is not apprehended. J. G. Clark 
found that flushing- the peritoneum 
with the solution greatly augmented 
leucocytosis, and advocates its use 



even in peritoneal infections. He 
makes it a practice to leave at least 1 
liter of solution in the peritoneal 
cavity even after the simplest opera- 
tions, not only the circulation, but 
also the kidneys, skin, intestines, and 
all other organs functionating better 
under its influence, thirst being re- 
lieved, and the virulence of infection 
being decreased. 

Contraindications. — Saline infu- 
sions are contraindicated in many in- 
stances of edema, especially where 
there is retention of sodium chloride 
in the system as a result of renal im- 
pairment, and in pulmonary edema. 
Pure salt solution often fails to bring 
on diuresis in cholemic states, prob- 
ably because of a prejudicial action of 
the circulating bile on the kidneys. 

Other Solutions. — The studies of 
Jacques Loeb have shown that a 
solution of pure sodium chloride in 
distilled water has poisonous proper- 
ties owing to the complete absence of 
other salts, especially those of calcium 
and potassium. As the tap-water gen- 
erally employed in the preparation of 
normal saline solution is likely to 
contain some calcium salts, but little 
of which is required to ofit'set the 
poisonous influence of the sodium, no 
difficulty from the use of the ordinary 
normal saline solution is, as a rule, 
experienced. The possibility of dan- 
ger from excessive displacement by 
sodium chloride of the calcium and 
potassium salts known to be essential 
to the vitality of the body cells is 
recognized, and Thies has advised 
against the use of pure normal so- 
dium chloride solution, especially in 
small children with disorders asso- 
ciated with a considerable elimination 
of salts, in inanition from pyloric 
stenosis or other cause, in cachexia, 



200 



SPIGELIA. 



in conditions entailing changes in the 
kidneys or cardiovascular system, and 
in febrile affections, in which elimina- 
tion of salts other than those of so- 
dium is augmented. Thies recom- 
mends for rectal introduction a solu- 
tion containing 0.6 per cent, of sodium 
chloride and 0.02 per cent, each of 
calcium chloride and potassium chlo- 
ride, and for hypodermoclysis, one 
containing 0.85 per cent, of sodium 
chloride and 0.03 per cent, each of 
the other salts. Among other im- 
proved substitutes for normal sodium 
chloride solution are : — 

Dawson's solution, containing 0.8 per 
cent, of sodium chloride with 0.5 per cent, 
of sodium bicarbonate. 

Locke's solution: Sodium chloride, 0.9 
per cent.; potassium chloride, 0.042 per 
cent.; calcium chloride, 0.024; sodium bi- 
carbonate, 0.03, and dextrose (glucose), 
0.1 in distilled water. (Schiassi would re- 
duce the potassium salt to 0.0075 and the 
calcium salt and bicarbonate each to 0.01.) 

The Ringer-Locke solution, like the pre- 
ceding, but with the nutrient dextrose 
omitted. 

Fleig's solution: Sodium chloride, 0.65 
per cent.; potassium chloride and mag- 
nesium sulphate, of each 0.03; calcium 
chloride, 0.02; sodium bicarbonate, sodium 
glycerophosphate, and dextrose, of each 
0.1, in distilled water. Oxygen, ad satu- 
randum, may with advantage be added. 

H. M. Adler's solution: Sodium chloride, 
0.59 per cent.; potassium and calcium 
chlorides, of each 0.04; magnesium chlo- 
ride, 0.025; sodium dihydrogen phosphate, 
0.0126; sodium bicarbonate, 0.351, and glu- 
cose, 0.15. This solution, on one occasion, 
maintained rhythmic contractions of an 
isolated cat's heart for twenty-one hours, 
and is intended to provide a mechanism 
for maintaining the reaction of the blood, 
for neutralizing acids and alkalies, and for 
the transport of a sufficiently large amount 
of carbon dioxide. 

Fischer's solution, containing 1.4 per 
cent, of sodium chloride and 1 per cent, 
of crystallized sodium carbonate, has been 
recommended by W. M. Brown for rectal 



or oral introduction in puerperal eclamp- 
sia to maintain a proper circulatory vol- 
ume after eliminative treatment by ca- 
tharsis, hot packs, colon irrigations, or 
venesection. 

Fischer's solution used in a case 
of vomiting of pregnancy where 
other measures had failed, giving 20 
grains (1.3 Gm.) of sodium bromide 
dissolved in a pint (500 c.c.) of this 
solution per rectum by the drop 
method. A patient with chronic myo- 
carditis, mitral regurgitation, and a 
moderate degree of arteriosclerosis, 
with general edema and vomiting, 
was put on Fischer's solution per 
rectum by the drop method and 
passed a gallon of urine inside of 
fourteen hours. Post-partum eclamp- 
sia, coming on in a primipara who 
failed to respond to the ordinary 
treatment, was successfully treated 
by venesection, followed by intraven- 
ous infusion of 1^4 pints (750 c.c.) of 
Fischer's solution. Southworth (Lan- 
cet-Clinic, Sept. 5, 1914). 

A study of antianaphylactic im- 
munization with sodium chloride 
showed that when a second injection 
of horse serum is to be given to an 
animal which 3 weeks previously had 
been given a preliminary injection of 
this serum, the violent anaphylactic 
reaction, which is frequently lethal 
within a short time, may be pre- 
vented by the use of a serum which 
has been diluted with 9 times its vol- 
ume of isotonic sodium chloride solu- 
tion. Where this is done the reaction 
is of only moderate intensity, and the 
animal quickly recovers. If the solu- 
tion is injected before the serum a 
much larger quantity of salt is re- 
quired. Richet, Brodin and Saint- 
Girond (Presse med., July 24, 1919). 

L. T. DE M. Sajous. 

Philadelphia. 

SPIGELIA.— Spigelia (pink-root; 
Maryland, Carolina, or Indian pink; 
worm-grass, worm-weed, starbloom) is 
the dried rhizome and roots of Spigelia 
viarilandica (fam., Loganiaceae), growing 
in thickets from Pennsylvania to Illinois 
and southward. The active constituent is 



SPINAL ANESTHESIA (BABCOCK). 



201 



apparently a volatile, crystalHzable alka- 
loid, spigeline, which is soluble in both 
alcohol and water. There is also present 
a small amount of volatile oil, fat, wax, 
tannin, and a tasteless resin. 

PREPARATIONS AND DOSES.— 

Sfigclia, U. S. P. (spigelia). Dose of 
powder, 10 to 20 grains (0.60 to 1.30 Gm.) 
to a child under 5 years of age, and from 
^ to 2 drams (2 to 8 Gm.) to an adult. 

Fhiidcxtractum spigelicc, U. S. P. (fluid- 
extract of spigelia). Dose', 10 to 20 
grains (0.60 to 1.30 c.c.) to a child of 5 
years, and from Yz to 2 drams (2 to 8 c.c.) 
to an adult. 

The fluidextract of spigelia and senna, 
formerly official, is a convenient and ac- 
tive preparation, and may be given in the 
same dose as the official fluidextract of 
spigelia, preferably in simple syrup, or 
with aromatics. 

PHYSIOLOGICAL ACTION. — Spi- 
gelia is a popular and efficient anthelmin- 
tic against roundworms (Ascaris lumbri- 
coides). It has some cathartic action, but 
as this is uncertain it is usually com- 
bined with senna, Epsom salt, or other 
cathartic. When purgation is lacking or 
tardy cerebral symptoms may present, as 
vertigo, dimness of vision, strabismus, 
mydriasis, and even convulsions. 

POISONING BY SPIGELIA.— Toxic 

doses produce a hot, dry skin and fauces, 
accelerated circulation, dilated pupils, in- 
ternal strabismus, exophthalmos, general 
motor paralysis, drowsiness, passing into 
coma and slow respiration. Death oc- 
curs from paralysis of the respiratory 
center. 

THERAPEUTIC USES.— Spigelia is 
chiefly useful as an anthelmintic against 
roundworms (Ascaris lumbricoides) and 
ranks as one of the best. It is always 
best to administer a dose of a saline, like 
magnesium citrate or sulphate, about two 
hours after taking spigelia. W. 

SPINAL ANESTHESIA.— In 

spinal anesthesia or anal<4esia, or, bet- 
ter, subarachnoid anesthesia, insensi- 
bility of portions of the body is 
produced by the injection of local 
anesthetic drugs into the subarach- 



noid space in the spinal canal. The 
method may more properly be termed 
a nerve-root than a spinal anesthesia, 
since it is the sensory nerve-roots as 
they meet the spinal cord, rather than 
the cord itself, v^^hich are anesthetized. 
The term lumbar anesthesia, some- 
times (ised, applies definitely to an- 
esthesia induced by injection in the 
lumbar portion of the spinal column. 
Sacral or caudal anesthesia is to be 
clearly dififerentiated from the usual 
type of spinal anesthesia, in that the 
anesthetizing injection is made, not 
into the subarachnoid space, but in 
the sacral canal below and outside 
the dura covering the nerve-trunks of 
the Cauda equina. This procedure 
will be taken up in a separate section 
at the close of this article. 

To J. Leonard Corning, of New 
York, belongs the credit of first ap- 
plying the principle of conduction 
anesthesia to the structures enclosed 
in the spinal canal. In 1888 spinal 
(extradural) injections of cocaine 
were made by him for the relief of 
pain in 4 cases of spinal disease, but 
it was not until 1899 that actual intra- 
dural anesthesia with cocaine was 
attempted by August Bier, of Bonn. 
Others soon adopted the procedure, 
often only to abandon it later owing 
to the unpleasant and at times fatal 
results attending tlie use of cocaine. 
In 1904 a long step forward was 
made in the substitution for cocaine 
of the less toxic stovaine, discovered 
by Fourneau in the preceding year. 
Numerous further improvements in 
the technique since that time have 
done much to popularize the proced- 
ure, and have reduced its disadvan- 
tages as compared to other major 
forms of anesthesia — practically to 
the vanishing point. 



202 SPINAL ANESTHESIA (BARCOCK). 

PHYSIOLOGICAL ACTION.— centration of the drug used, ranging 

The action of the various drugs from as little as twelve minutes to 

which have been used in spinal an- two hours. After the full adult dose 

esthesia is so similar that a single the average duration of analgesia is 

description will answer for all. The from one to one and a half hours, the 

spinal cord occupying less than one- effect beginning slowly to recede 

half tlie anteroposterior and trans- from its maximum fifteen or twenty 

verse diameters of the spinal canal, a minutes after the injection. Whereas 

considerable space, filled with cere- 0.05 or 0.06 Gm. (}i to 1 grain) of 

brospinal fluid, exists between it and stovaine in 4 per cent, solution will 

the surrounding arachnoid and dura! produce an analgesia lasting about 

membranes. An anesthetic drug in- ninety minutes, the effect from a 0.02 

jected into this space comes in con- or 0.03 Gm. (^ to % grain) dose in 

tact, not only with the spinal cord, the same concentration will persist 

but with the motor and sensory only fifteen or twenty minutes, 

nerve-roots, the conductive power of The abdominal walls being relaxed 

which it arrests, causing anesthesia, in spinal anesthesia, the abdomen be- 

motor paralysis, and sympathetic pa- comes partially scaphoid, and abdom- 

ralysis in the segments involved. The inal breathing, except from the dia- 

spinal cord itself is but superficially phragm, is practically abolished. The 

influenced, and its columns may con- intestine is largely released from 

tinue their functional activity dur- sympathetic inhibition through pa- 

ing the anesthesia. The autonomic ralysis of the rami communicantes. 

system, likewise, remains practically and tends, therefore, to contract, the 

uninfluenced. gaseous and liquid contents of the 

The action of the drug begins in a large intestine not infrequently es- 

few seconds after its injection, and caping — an advantage in ileus — as the 

the patient immediately notices a anal sphincters are simultaneously 

paresthesia of the feet, followed very relaxed. Peristalsis is, to a slight 

promptly by insensibility and almost extent, similarly stimulated in the 

complete motor paralysis. The pain stomach. Where the upper dorsal or 

sense is more markedly and exten- cervical segments become involved in 

sively paralyzed than the tactile the anesthetic action, nausea, usually 

sense; thus, if the anesthesia be not very transient, and caused probably 

deep, the contact of the knife during by cerebral anemia, is frequently ex- 

the incision may be felt, though no perienced. Vomiting is difficult un- 

pain is experienced. Sensation is lost less the head and chest be lowered, 

before the power of motion, which The eft'ect of spinal anesthesia on 

may therefore persist during the an- the circulation is to produce a reduc- 

algesia if a weak solution of the lion in the pulse rate and blood-pres- 

anesthetic is used. With sufficient sure, which is proportionate to the 

dosage, however, the patient becomes intensity of the anesthesia, and, in 

completely unaware of the position or particular, to its height in the spinal 

movements of the lower limbs. canal. Where only the lower spinal 

The duration of the analgesia va- segments are involved these changes 

ries markedly with the dose and con- are likely to be but slight, but if the 



SPINAL ANESTHESIA (BABCOCK). 



203 



upper dorsal nerve-roots are reached 
the pulse rate may drop to 40 or 30, 
and the blood-pressure to zero at the 
wrists. These effects, which may be 
ascribed to vasomotor paralysis in the 
involved segments, to absence of op- 
position to cardioinhibitory vagal ac- 
tivity owing to paresis of the sym- 
pathetic accelerator mechanism, and 
probably to other factors, begin in 
about fifteen or twenty minutes after 
the injection, and gradually subside 
after a time. No other anesthetic in- 
duces so complete a vasomotor relax- 
ation^, though if the breathing is well 
maintained, even a zero blood-pres- 
sure at the wrist may be innocuous. 

Respiration is affected, even in an- 
esthesia limited to the lower dorsal 
segments, in that the co-ordinate 
movements of the abdominal walls 
are lost, the respirations becoming 
exclusively diaphragmatic. If the 
action extends sufficiently high to 
relax the chest walls, a sense of 
weight or thoracic oppression may be 
experienced, and if the fourth cervical 
segments supplying the phrenics are 
reached, progressive asphyxia rapidly 
follows, unless efficient artificial res- 
piration is instituted. The breathing 
in spinal anesthesia is, on the whole, 
slow and rather shallow. Cyanosis is 
ominous, and necessitates immediate 
inquiry into the possibility of ob- 
struction to the upper respiratory 
passages, to be followed by artificial 
respiratory measures if no improve- 
ment is obtainable in this direction. 

The skin during spinal anesthesia, 
unless it extends high up, remains of 
normal color or becomes slightly 
pale. The sweating and suffusion of 
ether anesthesia are conspicious by 
their absence. The urinary sphincter 
is probably not relaxed, no inconti- 



nence of urine having, in my experi- 
ence, been observed. The uterine 
contractions are weakened, but not 
abolished, by the procedure. The 
uterus contracts promptly after de- 
livery. Hemorrhage during delivery 
or curetment for miscarriage is less 
than that occurring under chloroform 
or ether. 

TECHNIQUE.— Solutions Used.— 
The numljer of the spinal segments 
influenced in subarachnoid anesthesia 
depends not only upon the dosage 
and bulk of the injection, but also 
upon the : ~2cific gravity of the solu- 
tion used, and the posture of the pa- 
tient after the injection. Although 
the specific gravity of the cerebro- 
spinal fluid is relatively constant, 
ranging almost invariably between 
1.0055 and 1.0065, it is impracticable 
to use an anesthetic solution of ap- 
proximately a like specific gravity 
with the expectation that it will re- 
main indefinitely at the level of its 
introduction in the spinal' canal. The 
slightest variations in the specific 
gravity of the cerebrospinal fluid 
causing the solution to rise or fall, 
it is desirable to use a solution either 
distinctly heavier or lighter than the 
cerebrospinal fluid. An increased 
specific gravity may be obtained by 
adding to the solution a little glucose, 
lactose, dextrin, or mannitol. Thus, 
Barker injects a 5 per cent, solution 
of stovaine in a 5 |)er cent, solution 
of glucose, the patient lying on the 
side, with shoulders and hips slightly 
elevated, .\fter the injection the j^a- 
tient is cautiously rolled on the ])ack, 
the elevation of the shoulders and 
hips being maintained witli suitable 
pads or boards. The nerve-roots of 
the lower dorsal region are thus 
chieflv anesthetized. 



204 SPINAL ANESTHESIA (BABCOCK). 

Since it is often desiral)le to operate The heavy solution is intended for 

with the patient in the Trendelenburg cases in which it is desirable to ele- 

posture or to lower the head where vatc the head and shoulders of the 

marked circulatory depression exists, i)c-iticnt during the operation. 

1 have been in the hal)it of employing, Stovaine, the drug generally em- 

in most instances, a solution lighter ployed, is the most powerful anesthe- 

than the cerebrospinal tluid, the pa- tic and motor paralyzant of the three, 

tient being quickly laid on the opcrat- though likewise the most toxic, most 

ing table, with his shoulders about actively hemolytic, and the strongest 

two inches lower than his hips, after protoplasmic poison. Tropacocaine is 

the injection. Having experimented, somewhat less active as an anesthetic, 

as anesthetic drugs, with cocaine, while novocaine, though less toxic 

alypin, eucaine lactate, chloretone, and non-hemolytic, is the least effi- 

stovaine, tropacocaine, and novocaine, cient of the three, and may not pro- 

I have been led to discard all but the duce complete muscular relaxation 

last three, the following formulas be- even if analgesia exists, 

ing at present used : — Avoidance of toxic effects from this 

Light Solutions type of anesthesia necessitates care- 

A. Stovaine 0.08 Gm. {V4 gr). ful preparation of the solutions to be 

Lactic acid 0.04 c.c. (% min.). used. These are best kept in sealed 

Absolute alcohol... 0.2 c.c. (3i/< min.). ampoules, each containing 2 c.c. (32 

Distilled water L8 c.c. (30 min.). minims) of solution, and should be 

B. Tropacocaine 0.1 Gm. (114 gr.). prepared under aseptic precautions 

Absolute alcohol... 0.2 c.c. (3/, min.). ^^^^ sterilized, not by boiling, but by 

Distilled water L8 c.c. (30 min.). ■ ^ -j.^ . , ^ 

intermittent exposure to a tempera- 

C. Novocaine 0.16 Gm. (2/. gr.). ^^^^.^ ^^^^ exceeding 65° C. (149° F.). 

Absolute alcohol... 0.2 c.c. (3'/> min.). rr^i , r i i i, r i r 

n- ,„ . , lo /OA • N ihe dose, for the adult, of each ot 

Distilled water 1.8 c.c. (30 mm.). _ ' , '_ 

the solutions mentioned is 1 to IJ/2 

Heavy Solution. , , , _ , . . n , , , 

.. ^ . ^^.^ ^ ,, . \ c.c. (16 to 24 minims), the larger 

D. Stovaine 0.08 Gm. (1^ gr.). ^ , . , , • , , . 

r ,• •, nn/1 /"/ • \ amount being used only in the robust. 

Lactic acid 0.04 c.c. (7^ mm.). 5' -^ 

Milk sugar (lac- Children withstand relatively large 

tose) 0.1 Gm. (IK' gr.). doses. Thus, 0.015 Gm. (^4 grain) of 

Distilled water, to stovaine, may be given in the new- 

"^^^^ 2.0 c.c. (32 min.). y^^^.^^ q Q3 q,^^ ^y^ gj.j^j„) ^^ ^ ^j^jlj 

The addition of 10 per cent, of al- of 5 years of average size and robust- 

cohol to the 4 per cent, stovaine solu- ness, and 0.04 Gm. {% grain) to a 

tion reduces its specific gravity to child of 10. 

about 0.992, causing it to ascend in Site of Injection, — The action of 

the spinal canal, with the patient sit- the anesthetic drug in spinal anesthe- 

ting up, at a rate approximating 10 sia is tide-like, the influence grad- 

centimeters (4 inches) a minute. The ually extending upward and, less 

lactic acid is added to the stovaine noticeably, downward in the suba- 

solutions to retard its precipitation rachnoid space from the point of in- 

by the alkaline cerebrospinal fluid, jection. The highest nerve-roots in 

stovaine having the alkaloidal prop- the range of diffusion of the drug 

erty of being precipitated by alkalies, having been reached, the tide of 



SPINAL ANESTHESIA (BABCOCK). 



205 



analgesia gradually recedes toward 
the spinal segments close to the point 
of injection. The affected segments 
farthest from this point are thus sub- 
jected to the action of the drug in 
its most diluted form and for the 
least period of time. For prolonged 
and complete analgesia it is desirable, 
therefore, to inject the drug through 
an interspace adjacent to the nerve- 
roots corresponding to the field of 
operation. In operations on the 
perineum and anus, the injection is 
especially efficient if made through 
the third or fourth lumbar interspace, 
i.e., below the third or fourth verte- 
brae, respectively; in operations on 
the leg, through the second or third 
lumbar interspace; in those on the 
lower abdomen or groin, through the 
first lumbar interspace, and in those 
on the stomach, gall-bladder, or liver, 
through the twelfth dorsal interspace. 
A minimum dose injected through 
the last-named interspace, though it 
may suffice for upper abdominal 
work, may yield only a transient and 
patchy anesthesia for operations upon 
the legs or perineum. 

High spinal anesthesia or analge- 
sia involving the upper dorsal, the 
cervical, and the cranial segments 
may be produced by selecting a high 
interspace, especially the seventh 
cervical interspace as advocated by 
Jonnesco; by injecting a large quan- 
tity of a dilute anesthetic solution 
after withdrawing an equal quantity 
of cerel)rospinal fluid, or by causing 
upward diftusion of an anesthetic 
solution having a specific gravity dif- 
ferent from that of the cerebrospinal 
fluid. In some instances the with- 
drawn cerebrospinal fluid is used as 
the solvent for the anesthetic. As it 
is difficult to produce analgesia with- 



out motor paralysis, shock, uncon- 
sciousness, respiratory and cardiac 
arrest, and especially blocking of the 
phrenics are not uncommon. To 
avoid these dangerous effects the dos- 
age must be much reduced, so that a 
very brief, and at times imperfect, 
analgesia is produced. JonnescO' ob- 
tains an analgesia of about fifteen 
minutes' duration, and attempts, but 
imperfectly, to increase the safety of 
the injection by the addition of 
strychnine. While it is possible to 
do even craniotomies under high 
spinal anesthesia, the brevity of the 
effect, and especially the great dan- 
gers incurred, preclude its adoption 
as a justifiable method of anesthesia. 
Only when a drug is found capable 
of arresting sensory without motor 
conduction will high spinal anesthe- 
sia deserve consideration. 

Syringe and Needle. — A glass 
syringe of the Luer type of 2 c.c. 
capacity, graduated with 0.1 c.c. di- 
visions, is to be given preference. 
The piston of such a syringe, when 
properly made, fits loosely enough to 
be forced out by the pressure of the 
intradural fluid — an important feature 
in showing that the needle has en- 
tered the subarachnoid space. 

To insure delicacy of manipulation, 
the needle should likewise be small 
and light. It should be of iridium- 
platinum or gold, to insure against 
Ijreakage, and should be about 7 cm. 
long and 1 mm. in diameter. The 
point should be very sharp, but very 
oblique, so that the length of tlie 
bevelled portion shall be only about 
2 mm. The needle should be pro- 
vided with a well-fitting stylet, that 
its lumen may not become clogged 
during its introduction. It should fit 
the syringe accurately. 



206 



SPINAL ANESTHESIA (BABCOCK). 



The syringe, needle, and stylet 
shciuld be wrapped in gauze and 
boiled in water free from alkali for 
fifteen minutes just before using. 
(The addition of an alkali may de- 
compose the anesthetic drug.) The 
apparatus should be brought to the 
operator while still very hot, not only 
to insure sterility, but also in order 
that the syringe may warm the an- 
esthetic solution. The assistant open- 
ing the ampoule for the operator 
should previously have wiped the 
surface of the ampoule with a bit of 
gauze moistened with alcohol. 

Preliminary Narcotization. — Reten- 
tion of consciousness by the patient 
while in the operating room being 
often objectionable, it may in many 
instances be obviated by the prelimi- 
nary injection of narcotics. In a ro- 
bust adult % grain (0.01 Gm.) of 
morphine sulphate and %oo grain 
(0.0006 Gm.) of scopolamine hydro- 
bromide are given hypodermically. 
about seventy-five minutes before the 
time of operation. If in twenty min- 
utes the patient answers questions 
without evidence of mental confusion, 
the injection is repeated, and in cer- 
tain very resistant patients a third 
injection of morphine, either alone or 
combined with Yi-y grain (0.004 Gm.) 
of apomorphine hydrochloride, if the 
delirlfacient scopolamine action pre- 
dominates, or of both morphine and 
scopolamine if the previous injections 
have produced little effect, is later 
given. In patients under 30 years of 
age, in whom the delirifacient scopo- 
lamine action often predominates, the 
initial injection may consist of y^ 
grain (0.016 Gm.) of morphine and 
Vi5o grain (0.0004 Gm.) of atropine. 
Such narcotization intensifies and 
prolongs the action of spinal anesthe- 



sia. Properly applied, it enables the 
I-iatient to pass through the operation 
oblivious of the fact that he has been 
removed from liis l)ed. In shocked, 
debilitated, or aged patients it should, 
liowever, be employed with the 
greatest care, or avoided ; likewise, 
in patients w^ith marked respiratory 
depression, grave renal disease, or 
marked toxemia. Narcotics have 
been used in about 85 per cent, of 
our cases. 

Consciousness may also be dulled 
by the administration of ether or 
other anesthetic by inhalation. Often 
a minute amount of ether will divert 
the mind or slightly obtund con- 
sciousness during the operation. 

In children, narcotics are rarely 
required. After the spinal injection 
the child, if properly reassured as to 
the numbness and loss of power in 
the legs, will often fall asleep during 
the operation. 

Associated Local Anesthesia. — 
A\'here the operator finds it necessary 
to extend his incision above the level 
of the analgesia, or the operation is 
so prolonged that the spinal effect in 
part passes oft", a 1 per cent, solution 
of novocaine in saline solution may, 
with advantage, be used locally for 
the skin and subcutaneous tissues, 
and a 0.25 per cent, solution for the 
deeper tissues. In very extensive 
amputations it may be desirable to 
inject a 2 per cent, novocaine solution 
in the important nerve-trunks, not 
only to guard against imperfect ar- 
rest of conduction in the spinal nerve- 
roots, but also as an aid in prolonging 
the local analgesia. 

Induction and Management of 
Spinal Anesthesia, — Tlie patient's 
back, before he is brought to the op- 
crating room, is scrubbed with ace- 



SPINAL ANESTHESIA (BABCOCK). 207 

tone and painted with a 2.5 per cent, should be inserted close to the mid- 
tincture of iodine ; a dry, sterile line, at about the vertical center of 
binder is then applied. In the oper- the interspace, at right angles to the 
ating room the patient is sat across body surface, and carried directly 
the middle of the operating table, the forward until it is grasped by the 
binder removed, and the back either dense interspinous ligament. (In the 
flushed with alcohol or given a sec- dorsal region it is necessary to tilt 
ond coating of dilute iodine tincture, the needle somewhat upward.) The 
The assistant sees to it that the pa- grasp of the needle by the interspin- 
tient is sitting squarely across the ous ligament — often cartilaginous in 
table, that his hips are even, elbows its consistency — usually indicates that 
parallel and at the sides,^ and the it is being passed in the proper direc- 
forearms crossed in front of the body. tion. If it encounters only loose tis- 
Facing the patient, he then stands on sue, it has probably deviated laterally, 
a low stool and holds the patient's and should be withdrawn and reintro- 
hands with his own right hand, while duced with more accurate orientation, 
liis left arm encircles the back of the The stylet is now withdrawn and 
patient's neck and his fist makes pres- the needle cautiously pushed forward 
sure against the patient's abdomen, with short, quick strokes, a few milli- 
The patient's chin is thus forced meters at a time. A cessation of re- 
down on his chest and the back sistance is noted as the needle-point 
arched without allowing him to lean leaves the interspinous ligament and 
forward. enters the loose areolar tissue outside 

The spinal interspace, through the dura, followed by slight resist- 

which it is desired to inject, is ance and a snap — sometimes audible 

now located. This may be done by — as the tense dura is punctured, 

stretching a sterile towel between the Finally, the needle is partially rotated 

iliac crests; its upper edge will cross to insure complete penetration of the 

the fourth lumbar spine or interspace, dura by its point. Cerebrospinal fluid 

Or, the interspace opposite the angle should now drop fairly rapidly from 

formed by the last rib and the erector the needle; if it does not, the needle 

spinas muscle may be noted; this is may be cautiously rotated or slightly 

the first lumbar. From one of these moved until the fluid flows freely. At 

known interspaces the desired space times it is necessary to reintroduce 

may be ascertained. the stylet, cautiously aspirate with 

The injection should be made im- the syringe, or seek another inter- 
mediately before the operation, to space, the latter being usually the 
avoid diffusion of the anesthetic and best plan where there is much diffi- 
earlier loss of the effects. After culty with the first attempt. At 
drawing the contents of the sterile times, if the needle enters directly in 
ampoule into the syringe, air-bubbles the median line, a few drops of blood 
and any excess of the solution beyond may flow from the venous plexus out- 
the dose to be injected — usually 1.2 side the dura; this apparently does 
to 1.5 c.c. (20 to 25 minims) — ex- no harm, and the blood is usually 
pelled. The needle, detached from quickly followed by cerebrospinal 
the syringe but containing the stylet, fluid. 



208 



SPINAL ANESTHESIA (HABCOCK). 



Only when the fluid is running 
freely should the charged syringe be 
adapted to the needle. The piston is 
first drawn out a short distance to 
permit cerebrospinal fluid to enter 
the syringe and mix with the anes- 
thetic solution, as well as again to 
prove that the needle has been prop- 
erly introduced. If a thorough difl^u- 
sion is desired, a part of the mixture 
may now be injected, more cerebro- 
spinal fluid drawn into the syringe, 
and this process repeated two or 
three times until the syringe is empty. 
Not over twenty seconds, however, 
should be consumed in giving the in- 
jection. 

Finally, the needle is quickly with- 
drawn and, if a light solution has 
been used, the patient at once laid 
upon the table, slightly tilted with 
the head down, to be maintained in 
that position at least twenty minutes, 
or, if a heavy solution has been in- 
troduced, the head and shoulders 
kept elevated. Analgesia should de- 
velop in two or three minutes, and is 
determined by watching the face as 
the skin is pinched. If no analgesia 
is present after six minutes, the in- 
jection may be repeated, in the same 
dosage, and, perhaps, through an- 
other interspace. 

During the operation the pulse and 
respiration should be continuously 
watched, the latter by observation of 
the to and fro movements of a wisp 
of cotton afiixed to the end of the 
nose. Diverting conversation is often 
desirable in the minority of cases in 
which the patient is awake. Should 
the patient exhibit evidences of nau- 
sea, the head and shoulders must be 
lowered by further inclination of the 
table and a careful watch kept for 
respiratory depression or a fall of 



blood-pressure. The latter, in the 
absence of respiratory arrest, need 
cause little alarm, but if the respira- 
tions become shallow or imperfect, a 
stimulating subcutaneous injection of 
4 grains (0.26 Gm.) of caffeine and 
YiQ grain (0.004 Gm.) of strychnine 
sulphate should be given, and the 
surgeon stand ready to practise arti- 
ficial respiration or an intravenous 
injection of epinephrin. 

After-treatment. — Sealing or dress- 
ing of the point of lumbar puncture 
in spinal anesthesia is unnecessary, 
no signs of infection having devel- 
oped in over 8000 anesthesias without 
the application of an occlusive dress- 
ing. 

In patients who have received pre- 
liminary narcotic injections, an enema 
of 2 quarts of warm water, to which 
may be added 2 ounces (60 Gm.) of 
glucose and 3 drams (12 Gm.) of 
sodium bicarbonate, should be slowly 
run into the bowel immediately after 
the operation, and every four hours 
thereafter for the first twenty-four or 
forty-eight hours the patient should 
receive from 4 to 8 ounces (120 to 
240 c.c.) of fluid by rectum. If the 
narcosis is too prolonged or intense, 
a pint (500 c.c.) of black coft'ee and 
2 drams (8 Gm.) of tincture of cap- 
sicum may be given with the first 
enema. Constant watching, to de- 
tect early and remove any cause of 
obstruction in the upper air-passages, 
is required in such deeply narcotized 
subjects. 

Spinal anesthesia does not contra- 
indicate the administration of water 
or bits of ice, either during or after 
the operation. Such food as seems 
best in the particular case may be 
given without regard to the fact that 
the patient has been anesthetized. 



SPINAL ANESTHESIA (BABCOCK). 209 

INDICATIONS AND ADVAN- resistant to many forms of treatment, 

TAGES OF SPINAL ANESTHE- were thus relieved by spinal anesthe- 

SIA. — Spinal anesthesia is applicable sia alone before an incision had been 

in patients of all ages, from the new- made. 

born to those in advanced life. It With one exception, during the 
can often be used where ether is in- past twelve years, I have selected 
admissible, as in patients with acute spinal anesthesia for all abdominal 
pulmonary or chronic cardiovascular operations on the toxic, septic, or 
disease, or is known already to have desperately sick, withholding opera- 
produced dangerous symptoms. tion only from those admitted to the 

Its chief value is in operations on hospital manifestly in a dying condi- 

the lower abdomen and pelvis. Prob- tion. It may be employed with un- 

ably no other form of anesthesia questionable advantage in abdominal 

yields as great a degree of muscular surgery in preference to ether where 

relaxation in these regions with as there exists an acute pulmonary or a 

little danger. Intra-abdominal ma- severe cardiac, vascular, or renal dis- 

nipulations are greatly facilitated by order, particularly when associated 

the relaxed parietes and contracted with high blood-pressure, 

intestine it affords. A shorter in- Operations on the pelvic organs 

cision may be made than under other are very conveniently carried out un- 

anesthetics, and the anesthetic does der spinal anesthesia. A most satis- 

not add to the patient's intoxication factory relaxation of the perineal 

nor impede elimination. Particularly muscles is afforded, and the relaxa- 

is the procedure valuable in acute tion of the anal sphincters — last to 

peritoneal infections, as from the ap- relax under ether, but among the first 

pendix. In such patients no preop- to relax under spinal anesthesia — fa- 

erative preparation is necessary be- cilitates operations on the lower 

yond the sterilization of the skin, and, bowel. In such cases an enema 

possibly, the passage of a stomach- should not be used for some hours 

tube. The lowest mortality I have before the operation ; the rectum 

obtained in operating on the appen- must, however, have previously been 

dix — 1.8 per cent, in a series of 220 thoroughly emptied, otherwise an 

consecutive and unselected cases, op- evacuation will usually occur on the 

erated promptly upon admission to table. 

the hospital, and irrespective of the In certain operations on the kid- 
degree or duration of any associated neys, spinal anesthesia seems espe- 
peritonitis — was secured with spinal cially valuable. Thus, I, have not 
anesthesia. hesitated to operate on these or- 

Where meteorism exists or there is gans simultaneously, nor to perform 

inflammatory ileus, evacuation of the nephrolithotomy on a residual kidney 

intestinal tract usually takes place after removal of the opposite organ, 

while the patient is on the operating In one woman, aged about 60, for 

table, and he returns to l)ed with a example, the residual kidney was 

scaphoid abdomen. Three patients, opened three times for recurrent cal- 

apparently with mechanical intestinal culi. From renal decapsulation per- 

obstruction of some days' duration, formed under spinal anestliesia for 



8—14 



210 SPINAL ANESTHESIA (BABCOCK). 

advanced nephritis, with or without spinal anesthesia, the heart action be- 
marked anasarca, i have observed no mg maintained during the interven- 
untoward effects. Spinal anesthesia tion by the intravenous use of 
seems also of especial value in blad- epinephrinizcd salt solution. In a 
der resection or removal for tumor, series of 14 cases of ruptured ectopic 
and in prostatectomy. pregnancy, some of the "tragic" type, 
In obstetrics spinal anesthesia is of which I operated by the vaginal route 
value to facihtate operative delivery, under spinal anesthesia, there was no 
As W. A. Steel has observed, hemor- mortaHty. J. P. Marsh, of Troy, N. 
rhage is markedly lessened in these Y., has reported 4 successive and suc- 
cases, and there is an immediate cessful Cesarean sections for eclamp- 
soothing mental effect on the patient sia under spinal anesthesia. It is 
owing to the cessation of her suffer- especially desirable for operative de- 
ing. The patient, holding to the side livery in this condition, owing to the 
of the bed, with the arms over her relaxation and lowering of blood- 
head, is enabled herself to render aid pressure induced, without interfer- 
in difffcult forceps deliveries. The ence w^ith elimination, 
uterine contractions are not abolished, In labor cases with heart disease 
and the placenta may be expelled spinal anesthesia relieves the patient 
spontaneously. No ill effects are pro- of all cardiac strain. H. R, M. Landis 
duced on the child. In private prac- has found that child-bearing may be 
tice the method enables the surgeon rendered relatively safe in tubercu- 
to handle emergency obstetric op- lous patients by instrumental delivery 
erations without an anesthetist or under spinal anesthesia. 
trained assistant. The procedure may The perineal anesthesia and mus- 
be employed in version or threatened cle relaxation afforded bv spinal an- 
uterine rupture. Uterine inertia is esthesia permit of immediate painless, 
probably less frequent than after thorough repair work on the birth 
ether. In breech or version opera- canal (Steel). 

tions the after-coming head must be Curettement for retained products 
extracted rapidly, or else the lower of conception is performed with much 
uterine segment may contract on the less hemorrhage than when ether or 
neck (Steel). chloroform is used. Reactionary hem- 
In exsanguinated obstetric patients orrhage seems to be less frequent, 
spinal anesthesia is frequently avail- Hematomas and hemorrhagic extrav- 
able where ether or chloroform would asations in wounds are uncommon, 
be contraindicated. In a case of in spite of the fact that fewer vessels 
Cesarean section, reported by J. C. require ligation in operations under 
Applegate, the uterus had ruptured spinal anesthesia than under ether, 
sixteen hours before the operation Spinal anesthesia prevents, to a re- 
and the fetus was in the abdominal markable degree, the production of 
cavity. Although the patient had to shock by operative measures carried 
be brought about twenty miles to the out under its influence (though it ac- 
hospital, and was pulseless and ap- centuates pre-existing shock). Its 
parently moribund when admitted, great rapidity of action — surgical an- 
she recovered upon operation under algesia being almost invariably in- 



SPINAL ANESTHESIA (BABCOCK). 



211 



duced within two minutes, and usu- 
ally in a still shorter time — is often a 
marked advantage. 

Secondary nausea or vomiting 
should not occur as a result of spinal 
anesthesia, and the patient should 
have less postoperative pain, less 
headahce, less backache, and less gen- 
eral discomfort than if he had re- 
ceived ether (J. O. Bower). The 
suffusion of the skin, drenching 
sweats, and heat radiation of ether 
are absent. Albuminuria does not 
occur. 

The repeated production of spinal 
anesthesia in the same person seems 
no more harmful than a single injec- 
tion. One patient was subjected to 
it no less than eleven times for re- 
peated plastic operations for hypo- 
spadias, without evidence of spinal 
cord or root injury. 

CONTRAINDICATIONS, — 
Whereas in aneurism, threatened de- 
compensation in valvular heart dis- 
ease, in the excessive vascular tension 
of eclampsia, in nephritis, and in ad- 
vanced arteriosclerosis the vasorelax- 
ation induced by spinal anesthesia 
may be of protective value, the pro- 
cedure should be used with care and 
diminished dosage, or avoided, in 
conditions of marked hypotension, 
e.g., in severe shock and where great 
depression or exhaustion of the spinal 
centers exists. Patients nearly or 
quite pulseless from traumatic shock 
should not, as a rule, be subjected to 
spinal anesthesia until reaction has 
occurred. The low blood-pressure 
induced favors cardiac arrest in cer- 
tain forms of myocardial disease, as 
well as in thoracotomy and other op- 
erations causing sudden changes in 
intrathoracic tension. 

Patients with advanced peritonitis. 



marked abdominal distention, and 
cyanotic extremities, especially when 
of the middle aged, obese type ; pa- 
tients in collapse from traumatic 
ileus ; patients with advanced septic 
disease of the biliary system and as- 
sociated marked myocardial weak- 
ness, and patients greatly depressed 
and toxemic, or with mechanical lim- 
itation of respiratory space, as from 
large serous or purulent effusions or 
massive intrathoracic growths, are 
not good subjects for spinal anesthe- 
sia. In patients in collapse from 
hemorrhage or with large fibroid tu- 
mors and myocardial degeneration 
the intradural injection should be 
given with great caution. 

Obese patients with a short, thick 
chest and limited breathing apparatus 
are less suited for the method than 
subjects with ample breathing space. 
Aged and debilitated patients should 
receive relatively small doses of the 
anesthetic drug. 

Greatly depressed subjects, who 
may be carried through an operation 
with local anesthesia or a few whiffs 
of ether, should not be given the 
spinal injection. 

Should spinal anesthesia be admin- 
istered to a person with marked cir- 
culatory hypotension, direct prepara- 
tions for intravenous introduction of 
epinephrinized saline solution should 
be made before the operation, as de- 
scribed in the following section. 

Spinal anesthesia should not be 
employed by those who have not de- 
veloped a trustworthy aseptic tech- 
nique or have not carefully mastered 
the physiology of the method, includ- 
ing an understanding of the dosage 
and mode of diffusion of the drug. 
Neither should the procedure be used 
if the patient cannot be properly 



212 SPINAL ANESTHESIA (BABCOCK). 

watched for one hour after the in- tions no anesthesia resulted, probably 

jcction, or if the operator is unprc- because the fluid was extradural. In 

pared to meet emeri;encies. rare instances the injection must be 

TECHNICAL DIFFICULTIES, repeated or another anesthetic used. 
COMPLICATIONS, AND SE- Dosage.— The chief drugs used in 
Q\JKL,JE. — Position of the Patient, spinal anesthesia are still under pro- 
— In rare instances a patient is un- prietary control and may not have 
able to breathe when recumbent. For been rigidly standardized, different 
such a subject a solution of high samples of a given drug appar- 
specific gravity should alone be used, ently showing variations in activity 
or, better, local anesthesia substi- amounting to as much as 30 per cent, 
tuted. In the ordinary case, in which At times we have found 0.04 Gm. (% 
the light solution is being used, the grainj of stovaine a proper dose, and 
patient should not be raised to a sit- again 0.06 Gm. (1 grain). As a 10 
ting posture for one-half hour after per cent, increase in the dose may be 
the injection, lest syncope be induced, dangerous, these variations in activ- 
Carrying the patient about after the ity necessitate great care in the em- 
injection is dangerous; without con- ployment of every new lot of the 
stant watchfulness the orderly or anesthetic. 

resident will lift or carry the patient Circulatory Depression. — In pa- 

with the head and shoulders raised, tients nearly pulseless, before the 

thus exposing the higher spinal seg- spinal injection, a needle connected 

ments to the action of the anesthetic, with a funnel containing physiolog- 

Breaking the Needle. — This mishap ical salt solution should be tied into 

occurred in my experience upon using a convenient vein before the opera- 

a very delicate, highly tempered steel tion is begun. The salt solution may 

needle in a young child, the needle then be run into the vein from time 

breaking when the child suddenly to time as indicated, from 1 to 10 

straightened the back ; removal of the drops of 1 : 1000 epinephrin solution 

fragment was soon successfully ef- being added to each 6-ounce (180 

fected. I know of no instance in Gm.) funnelful if the patient becomes 

which a platinum needle has broken actually pulseless at the wrist. The 

beneath the skin. introduction of epinephrin should be 

Lack of Anesthesia. — This may re- cut off by pinching the tubing as soon 

suit not only from the use of an im- as the pulse returns, for fear of an 

perfect solution, but from failure to excessive action upon the heart. For 

introduce the needle properly, or weak patients, not sufficiently asthe- 

from leakage of the solution outside nic to require the procedure just re- 

the arachnoid. In one kyphotic ferred to, the subcutaneous injection 

dwarf I failed to enter the spinal of 1 ampoule of pituitrin of 3 to 5 

canal. In two other patients the minims (0.18 to 0.3 c.c.) of epine- 

bony canal was entered, but no cere- phrin at the beginning of the opera- 

brospinal fluid could be obtained and tion may be of value. For nervous 

no very obvious analgesia followed, faintness, inhalation of aromatic spirit 

In still another case, fluid was ob- of ammonia, or a few drops of ether 

tained, but despite repeated injec- may be tried 



SPINAL ANESTHESIA (BABCOCK). 213 

Respiratory Depression. — To a Early After-effects. — Nausea and 
very weak subject, 4 grains (0.26 Vomiting. — In a large series of our 
Gm.) of caffeine and Yis grain (0.004 spinal anesthesia cases, 18 per cent. 
Gm.) of strychnine sulphate should had slight nausea and 13 per cent. 
be administered subcutaneously to an- vomited during the operation. This 
ticipate respiratory depression. The is probably due to involvement of the 
same injection should be given in upper dorsal nerve-roots by the an- 
other cases in which the respiration esthetic, with the resulting cerebral 
is observed to weaken. If the breath- anemia. The condition soon passes 
ing ceases, artificial respiration should off. 

be practised, most conveniently, as a Slight nausea and vomiting were 

rule, by rhythmic compression of the shown by 24 per cent, of the cases 

thorax, the surgeon clasping his after being returned to their beds, 

fingers down over the patient's ster- This was either associated with an 

num and making pressure downward intra-abdominal condition that would 

and inward sixteen to twenty times produce nausea or was secondary to 

a minute, a procedure which may be the use of morphine or other narcotic 

aided by the hands of the assistant, drug. On the whole, our impression 

placed under and below the elbows of is that spinal anesthesia does not pro- 

the surgeon. The patient's arms are, duce any postoperative vomiting un- 

meanwhile, extended above the head, less meningeal irritation occurs. The 

Oscillations of the cotton wisp on the showing in this respect is far more 

patient's nose prove the ef^cacy of favorable than that of our ether cases. 

the artificial respiration, which should Headache. — Mild headache followed 

be continued, if necessary, for one in 21 per cent, of our spinal anesthe- 

hour or more, or until the patient can sias. Fifty per cent, of the ether 

again breathe spontaneously. patients had headache, which was, as 

Where obesity or an abnormal a rule, more severe than after the 

intrathoracic state interferes with spinal procedure. We have recently 

the thoracic compression procedure, seen no severe headaches after the 

forced artificial respiration should be latter. Headache of the characteris- 

tried, either with the pulmotor or tic spinal type, i.e., increased by rais- 

lungmotor, if quickly available, or in ing the head from the pillow and 

a sudden emergency, by the insertion associated with some stiffness of the 

of a full-sized tracheal tube and di- neck muscles, indicates the use of a 

rect rhythmic inflation of the lungs contaminated or deteriorated solu- 

by the surgeon or assistant through tion, which should be promptly dis- 

a piece of drainage-tube cut off square carded. 

and held intermittently against the Backache. — Sixteen per cent, of our 

external plate of the tracheal tube. spinal anesthesia cases complained of 

Upon continuing artificial respira- this symptom, as against 61 per cent, 

tion until depression of the respira- of the ether cases, 

tory centers has passed off, the pa- Postoperative Pain. — The average 

tient, perhaps pulseless, relaxed, and duration of incisural pain after spinal 

pale, awakens as though miraculously anesthesia was twenty-nine hours, as 

resurrected. against forty-eight hours after ether. 



214 SPINAL ANESTHESIA (BABCOCK). 

Albuminuria. — Despite a number of headache and pain in the l)ack of the 

uranalyses, we have found no evi- neck. The period of incubation and 

dence that the intradural injection the associated mening^eal irritation 

irritates the kidneys. ^Fhis is corrob- sugj^est that the condition is due to 

orated by the tolerance of patients the use of a solution contaminated 

to repeated or extensive operations with bacteria. 

on the kidneys, in spite of existing Neurotic Symptoms. — Weakness of 

serious renal disorders. the legs, backache, headache, and 

Remote After-effects. — Injury to various pains are frequent after ab- 

Nervous Tissues. — Puncture of the dominal and especially after pelvic 

spinal cord by the needle produces operations, whether ether or spinal 

no symptoms, and, while it is to be anesthesia has been used. In the 

avoided, is relatively harmless. Lat- neurotic, especially those with pelvic 

eral deviation of the needle with in- symptoms, spinal anesthesia should 

jury to a nerve-root may, however, be accordingly be employed with cau- 

followed by a severe neuritis and tion. Such patients, particularly if 

secondary palsy, which is rarely per- influenced by prejudiced persons, will 

manent. Touching a nerve-root with often attribute all symptoms such as 

the needle-point produces a lightning- the above to the intradural injection, 

like pain usually radiating down the Mortality. — The safety of any an- 

leg. If this occurs the needle should esthetic depends, to a considerable 

be immediately withdrawn and rein- extent, upon the experience and skill 

troduced. of the user. In comparing the mor- 

Secondary degeneration of the tality from spinal with that from 
spinal cord from the chemical- action ether anestl^esia, one should be mind- 
of stovaine, as used in spinal anesthe- ful of the fact that the relatively 
sia, does not, in my opinion, in the favorable ether statistics frequently 
least degree occur. Experiments on quoted do not actually represent con- 
dogs in this connection are entirely ditions as they obtain in the general 
misleading, owing to anatomical dif- use of the drug, including its em- 
ferences and the differences in the ployment by the inexperienced and 
action of dilute and concentrated imperfectly trained, in sudden emer- 
solutions of stovaine. gencies, under unpropitious circum- 

Palsy of the abducens nerve, stances, and upon patients poorly 

though met with several times in our prepared for the anesthesia. Our 

earlier spinal anesthesias, has not oc- own experience with ether as admin- 

curred in a series of over 4000 recent istered by internes in hospitals, and 

injections. The condition is peculiar the results of inquiry into the ex- 

in developing in from seven to twelve perience, personal or otherwise, of 

days after the injection. Usually a several of my associates and assist- 

single abducens is involved, but at ants, suggests a mortality of about 1 

times the palsy is bilateral. Recov- in 500 in ether anesthesia, 

ery usually follows in from a few As for spinal anesthesia, from up- 

days to several months. Our cases ward of 5000 injections, including 

occurred in a period during which many administered by my assistants 

the anesthetic was often producing and associates, we have had 10 deaths 



SPINAL ANESTHESIA (BABCOCK). 



215 



on the operating table, and 1 death 
after operation, in which the anesthe- 
sia was a factor. Three of these died 
during- or after operations for large 
empyemas — a condition now recog- 
nized as contraindicating spinal an- 
esthesia. Two patients died under 
operations for gall-bladder disease 
associated with peritonitis ; one of 
these apparently was drowned by 
profuse, regurgitant vomiting as the 
operation was being completed, while 
the other was obese and had a seri- 
ous valvular lesion. Of the remain- 
ing 5 cases of early death three were 
nearly or quite pulseless before the 
anesthesia had been induced, the 
fourth was an infant with advanced 
general miliary tuberculosis, suc- 
cumbing during the search for an 
intrapulmonary abscess, and the fifth 
was an obese, elderly man with ex- 
tensive intestinal gangrene and diffuse 
peritonitis. These 5, properly to be 
considered as inoperable, were in a 
hopeless condition under any form of 
treatment. The eleventh case, that of 
an obese colored woman with a 
fibroid tumor, who died from circu- 
latory depression about two days 
after the operation, was the only fatal 
case in which the patient had been in 
even a fair condition at the time of 
anesthesia. 

In 4 of our spinal anesthesia cases 
attempts at etherization had been 
made in other clinics. In each case 
the operation had to be abandoned, 
as the patient collapsed, and it was 
evident that complete etherization 
would be fatal. In each of these pa- 
tients, without special preoperative 
treatment, the operation was suc- 
cessfully performed under spinal an- 
esthesia, with subsequent recovery. 
Similar results were obtained in sev- 



eral additional cases in which opera- 
tion had l)een refused at other clinics 
on account of advanced sepsis, old 
age, or other cause. 

On the whole, in our experience 
ether and spinal anesthesias have 
proven about equally dangerous, the 
former from exigencies necessitating 
a profound narcosis or the participa- 
tion of an imperfectly trained anes- 
thetist, the latter from faulty selec- 
tion of patients and, for a time, 
imperfect knowledge of the action of 
the anesthetic drug. These factors 
favoring a high mortality in spinal 
anesthesia having been eliminated, 
we have had no mortality from it 
during the past three years. Even if 
skillfully administered, spinal anes- 
thesia is probably more dangerous 
than a transient and light narcosis 
under ether or nitrous oxide-oxygen; 
but it is safer than is a prolonged 
narcosis with complete muscular re- 
laxation under ether or nitrous oxide- 
oxygen. Spinal anesthesia produces 
the greatest degree of muscular re- 
laxation with the least protoplasmic 
disturbance. The method has been 
repeatedly selected by my medical 
associates, assistants and nurses for 
operations on themselves or members 
of their families. 

Although relatively safe and very 
effective when used skillfully, spinal 
anesthesia is undoubtedly a danger- 
ous as well as unreliable procedure in 
the hands of those who do not under- 
stand its action. Ability properly to 
select patients suitable for its em- 
ployment is of paramount importance. 
For general, indiscriminate use ether 
remains the standard anesthetic de- 
spite its many drawbacks. The nov- 
ice should not attempt spinal anesthe- 
sia without careful investigation of 



216 



SPINAL ANESTHESIA (BABCOCK). 



the subject, and should apply it only 
in robust cases until due dexterity 
and familiarity with the technique 
have been acquired. 

SACRAL ANESTHESIA.— In this 
tyi)e of anesthesia, also termed epi- 
dural aiicstlicsia by Cathelin, its orig- 
inator, and extradural anesthesia by 
Lawen who, in 1910, hrst reported 
material success with it, an anesthetic 
solution is injected through the sacral 
hiatus into the pocket formed in the 
sacral canal below the level of the 
second sacral segment owing to the 
closure of the spinal dura mater 
around the nerve-trunks forming the 
Cauda equina. The method has also 
been termed caudal anesthesia. The 
sacral pocket referred to is com- 
pletely isolated by the dura from the 
subarachnoid space above ; none of 
the anesthetic solution, therefore, 
mixes with the cerebrospinal fluid. 
The areas affected in this procedure 
are merely those from which sensory 
nerve-fibers pass to the centers 
through the sacral plexus. In the 
sciatic distribution collateral innerva- 
tion maintains sensibility ; the fully 
anesthetized region, therefore, in- 
cludes only the perineum, the anus 
and lower rectum, the urethra and 
penis, the lower part of the prostate, 
the scrotum, but not its contents, and, 
in the female, the external genitals 
and vagina (P. Bull). 

Novocaine is the anesthetic drug 
generally used. Bull (1915) gener- 
ally injects 20 c.c. (5 drams) of a 2 
per cent, solution, plus epinephrin. 
Lewis and Bartels (1916j use from 
40 to 90 c.c. (1^ to 3 ounces) of a 
mixture in equal parts of 1 per cent, 
novocaine solution and 1 per cent, 
potassium sulphate solution, made 
with freshly distilled sterile water, 



with 2 drops of 1 : 1000 epinephrin 
solution added for each 30 c.c. (1 
ounce) of tiie combined solution. 

During the injection the patient is 
placed on his right side, with head 
slightly elevated and back strongly 
curved. After proper local cleansing 
the sacral hiatus is located, just be- 
low the spinous process of the sacrum 
and above the coccyx, in the midline. 
Lewis and Bartels infiltrate the skin 
and deeper soft tissues over the 
hiatus with the anesthetic solution 
before making the injection. The 
needle is first held at 45° with the 
skin surface, but as soon as penetra- 
tion of the ligamentous membrane 
covering the sacral hiatus is felt, the 
syringe is carried down almost to a 
level witli the body plane at that 
point, and the needle made to follow 
the axis of the sacral canal, into 
which it is introduced for a distance 
of V/i or 2 inches. If, in error, the 
needle has gone up too far and passed 
through the dura into cerebrospinal 
fluid, numerous drops of the latter 
will escape through the needle when 
the trocar wire is withdrawn. 

Care should always be taken, be- 
fore administering the injection, to 
ascertain that the needle has not 
entered a vein. The injection should 
be given slowly. 

The method differs radically from 
spinal anesthesia in the time required 
for development of the analgesic ef- 
fect, from eight to twenty minutes be- 
ing consumed in the permeation of 
the anesthetic through the dura cov- 
ering the nerve-trunks. The an- 
esthesia lasts for about an hour (Sie- 
bert). Relaxation of the sphincters 
and pelvic floor is a salient feature of 
the method. 

Lewis and Bartels report 13 pros- 



SPINAL CORD, DISEASES OF (PRITCHARD). 



217 



tatectomies, 68 cystoscopies, 2 cys- 
totomies, and 1 external perineal ure- 
throtomy performed under caudal 
anesthesia. In the cases of supra- 
pubic incision local infiltration anes- 
thesia at the site of incision was also 
used. Three of the prostatectomies 
required partial or complete ether 
anesthesia in addition. Among the 
68 cystoscopies there were 13 in- 
stances of only partial analgesia and 
5 of no analgesia (3 of these failures 
due probably to faulty technique). 
Bull reports imperfect anesthesia in 
15.6 per cent, out of 60 cases. 

Complications are uncommon and 
not dangerous. The method is 
deemed especially advantageous by 
Lewis and Bartels in aged bladder 
and prostatic cases already so re- 
duced by pain, back pressure, and 
toxemia as to possess no resisting 
powers to stand further depletion by 
other methods of anesthesia. Stoeckel 
(1909) applied the procedure in 141 
cases of childbirth, with distinct relief 
from pain in 111 cases. A tendency 
to arrest of uterine contractions when 
the injection was made at the be- 
ginning of labor was noted ; but 
when once the contractions had well 
started, there was no such effect. 
Successful results were also obtained 
with sacral anesthesia in 5 cases of 
dysmenorrhea. 

As long ago as 1901 Cathelin used 
injections of normal saline solution 
into the sacral canal for enuresis, 
tabetic crises, etc. 

Sacral anesthesia is, with difficulty, 
applied in the obese, the very nerv- 
ous or hysterical, and in children. 
According to Suchy, it is contraindi- 
cated in the alcoholic. 

W. Wayne Babcock, 

Philadelphia. 



SPINAL CORD, DISEASES 

OF. — GENERAL CONSIDERA- 
TIONS. — The diseases of the spinal 
cord, including the various congenital 
and acquired deformities and anoma- 
lies of development, together with the 
primary or complicating affections of 
the meninges, are more than fifty in 
'number. Of this list, infantile spinal 
paralysis, myelitis, and locomotor 
ataxia constitute collectively prob- 
ably three-fifths of all the cases. 
Locomotor ataxia has been described 
in a separate article ; so have multi- 
ple sclerosis and the forms of menin- 
gitis. Abscess of the cord is best 
studied in connection with caries of 
the vertebra, with which it is often 
associated. The non-traumatic vas- 
cular diseases of the cord — hemor- 
rhage, embolus, thrombus, and aneu- 
rism — are exceedingly rare, and this 
is true also of tumors, though perhaps 
less so. The spinal type of progres- 
sive muscular atrophy has been in- 
cluded among the diseases of the 
muscles. 

INFANTILE PARALYSIS; PO- 
LIOENCEPHALOMYELITIS. 

SYNONYMS.— Infantile spinal pa- 
ralysis ; myelitis of the anterior 
horns; acute atrophic paralysis; es- 
sential paralysis of children ; West's 
morning paralysis. 

DEFINITION.— An infectious dis- 
ease due to a minute micro-organism, 
characterized by a purely motor 
paralysis of flaccid type, occurring 
usually in young children, the paral- 
ysis being followed by rapidly de- 
veloping atrophy, with degenerative 
electrical reactions in the affected 
muscles. 

Not all children and relatively few 
adults are susceptible to infantile pa- 



218 



SPINAL CORD, DISEASES OF (PRITCHARD). 



ralysis. Young children are more 
susceptible, generally speaking, than 
older ones; but no age can be said 
to be absolutely insusceptible. When 
several children exist in a family or 
in a group, one or more may be af- 
fected, while the others escape or 
seem to escape. The closer the fam- 
ily or other groups are studied by 
physicians, the more numerous it 
now appears are the number of cases 
among them. This means that the 
term "infantile paralysis" is a mis- 
nomer, since the disease arises with- 
out causing any paralysis whatever, 
or such slight and fleeting paralysis 
as to be difficult of detection. Simon 
Flexner (Public Address, New York, 
July 13, 1916). 

An acute, a subacute, and a chronic 
form are recognized, the last com- 
monly observed in adults. 

Formerly our conception of the disease 
was that of a pure, flaccid motor paralysis 
without cranial-nerve involvement or cere- 
bral implication, the lesion being constant 
and limited to the giant cell of the anterior 
horns. Epidemics of poliomyelitis had 
been noticed, though infreqeuntly, and a 
growing belief existed in the theory of 
some specific micro-organism. 

Between 1902 and 1908 a number of en- 
demic outbreaks occurred in various sections 
of this and other countries, and such varia- 
tions from standard appeared in the* clinical 
picture as to modify completely its inter- 
pretation. Adults as well as children were 
attacked, many cases proved fatal, cranial 
nerves were frequently affected, sensory dis- 
turbances, though temporary, were, at 
times, conspicuous, and the gravest cere- 
bral complications were noted. The picture, 
in short, was that of involvement of the 
entire motor neuron system, cortex, basal 
and cord. This complex picture continued 
to be the rule up to within the past two or 
three years, since which time I have no- 
ticed a reversion to the old classic type. 
The final demonstration by Flexner and 
Noguchi of an almost ultra-microscopic or- 
ganism, capable of inducing the disease in 
monkeys and recoverable from its victims, 
establishes its etiology as one of specific 
infection. 



SYMPTOMS.— Trodromata are 
rare, as a rule. Irritability, malaise 
weakness, nausea, constipation or 
diarrhea, coryza, bronchitis, tonsillitis 
or restlessness may precede an at- 
tack. These may disappear com- 
pletely and be followed a few days 
later by poliomyelitis. Bronchopneu- 
monia may then develop owing to 
paralysis, or, at least, paresis of the 
respiratory muscles. 

The disease begins abruptly, usu- 
ally with some fe'ver. The tempera- 
ture may be only slightly elevated (1 
to 3 degrees), the range being higher 
and the fever more prolonged, the 
older the child. In the New York 
epidemic of 1907 the temperature 
ranged from 101° F. to 104° F. (38.3° 
C. to 40° C), but higher tempera- 
tures, 105° F. to 106° F. (40.5° C. to 
41.1° C), have, though rarely, been 
noted. A definite chill is also rare. 
There inay be slight digestive disor- 
•ders, such as vomiting and diarrhea, 
slight headache, and sometimes pain 
in the back and the limbs. These 
general symptoms vary in intensity 
with the temperature. In about one- 
fourth of all cases the onset of the 
disease may be marked by a convul- 
sive seizure. The younger the pa- 
tient and the higher the temperature, 
the more likelihood is there of con- 
vulsions, which, however, are rarely 
repeated more than once or twice. 
Some cases, however, run their 
course without fever. 

Headache is common, at least in 
patients old enough to complain. In 
the New York epideinic it was usu- 
ally general or frontal, but in cases 
observed by Wickman, it was occip- 
ital. It is moderately severe, as a 
rule, but is occasionally intense. 
Prostration is marked when the on- 



SPINAL CORD, DISEASES OF (PRITCHARD). 219 

set is sudden, as also in many mild before the onset of paralysis. It may, 

abortive cases. Albuminuria and however, be abolished on one side 

anuria are occasional ; incontinence and exaggerated on the other. 

rare. The bladder and rectum are After a few days — usually 2 or 3, 

not involved. rarely more than 10 — the fever and 

Besides the irritability observed, general disturbance subside, and not 

early excitement, restlessness, anxi- until then, usually, is the true nature 

ety, and mental perturbation are com- of the illness made evident by the 

monly noted. This is followed, par- discovery of a flaccid motor paralysis, 

ticularly in children, by a period of which may at hrst affect all of the 

apathy or drowsiness, with some extremities as well as the trunk-mus- 

confusion on waking. This confused cles. If suspected and sought for, 

state may lapse into mild delirium of however, the paralysis may often be 

short duration. Convulsions some- detected during the febrile stage, 

times occur also in children as Within a week or two the general 

noted above. On the whole, how- paralysis clears away, leaving a resid- 

ever, the patient tends to retain ual paralysis limited to one or more 

consciousness throughout the illness, limbs, or, it may be, to a single mus- 

even in lethal cases, and coma is cle or group of muscles. Such groups 

rare. Pain is complained of early, are invariably of muscles of asso- 

particularly in the back of the neck ciated function. The lower limbs are 

and spine. The pain in the face, arms, rather more frequently affected than 

and legs resembles that of myalgia, the arms. A paraplegic distribution 

but it may present the characteristics is common, a hemiplegic distribution 

of neuritis, with hyperesthesia and exceedingly rare. 

tenderness over the nerve-trunks. In perhaps one-fourth of all cases 

This may persist for weeks, but, as a among children the onset is even 

rule, the pains subside with or before more abrupt than as described. The 

the onset of paralysis. Again, menin- child may be put to bed in apparent 

gitic symptoms — stiffness of the neck good health, sleep quietly or perhaps 

and spine, contraction of the spinal a little restlessly through the night, 

muscles with retraction of the head — and is found the following morning 

may be noted. in addition to the pain bright, cheerful, and with a hearty 

in the same areas. Kernig's sign — appetite, but paralyzed in one limb, 

inability to extend the leg when the or, it may be, with a paraplegia, the 

thigh is flexed at right angle — is also affected limb hanging helpless and 

present in some cases. inert. Such cases were descrilsed in 

Both in cases which do not result the older literature as West's morn- 

in paralysis and those that do, mus- ing paralysis. 

cular twitchings, jerks and tremors Within 2 weeks usually, sometimes 

usually occur. They may first be much earlier, the muscles paralyzed 

elicited when the physical examina- begin to atrophy. The wasting some- 

tion is made, or during sleep, when times progresses rapidly. If the child 

they are most noticeable. At first the is fat, this atroi)hy may not be ap- 

patellar reflex is exaggerated, but it parent to the eye, but palpation will 

is invariably diminished or abolished at once make it evident. Not only 



220 



SPINAL CORD, DISEASES OF (PRITCHAKD). 



does tlie limb look wasted, but it 
usual 1\- presents a bluish, cyanosed 
appearance, and to the touch of the 
examiner it is distinctly colder than 
its fellow. The deep reflexes are lost, 
if affected at all. 

Simultaneousl}- with the atrophy, 
or it ma}' be a little later, an altera- 
tion both quantitative and qualitative 
may be noted in the response to both 
the faradic and galvanic currents. To 
the faradic current the muscular re- 
sponse is at first simply diminished. 
It grows more and more feeble from 
day to day, and is eventually lost 
completely in severe cases. To the 
galvanic current the nerves involved 
show at first beginning and later 
more or less complete reaction of de- 
generation. In making these elec- 
trical tests the corresponding sound 
muscles in the unaft'ected limb should 
be used for comparison. Minor 
changes can only be determined in 
this way. 

Within a few months various de- 
formities from contraction and unop- 
posed muscular antagonism may de- 
velop. Talipes varus and -equinus, 
and many other deformities are pos- 
sible. Sometimes an arrest of de- 
velopment occurs, one limb after a 
few years being shorter than the 
other, or one hand or foot smaller 
than the other. 

Chronic poliomyelitis is one of 
the forms of progressive muscular 
atrophy arid, together with the sub- 
acute variety, dififers chiefly in the 
mode of onset and rate of progress, 
but not the nature of the paralysis. 

Individual cases so varv from the 
classic type in recent years as to 
suggest the presence of different af- 
fections. Wickman, of Stockholm, 
Sweden, after a careful study of the 



Scandinavian epidemic, and a clinical 
study of 1025 cases, showed, how- 
ever, that all the supposed disorders 
were but different forms of the same 
disease. An analysis of W'ickman's 
paper, by Ur. W. R. Ramsey, of St. 
Paul {Jour. Minnesota State Med. 
^■Issoc, Dec, 1909), so ably summar- 
izes this important contribution that 
it is reproduced below as accurately 
descriptive of the disease as we have 
been seeing it in the past ten or fif- 
teen years. 

Poliomyelitic Form. — The sickness al- 
most always begins acutely with fever 
and general indisposition. The expressed 
opinion of several authors, that in a great 
percentage of the cases the paralysis ap- 
pears without preceding initial symptoms, 
is certainly incorrect and rests upon in- 
sufficient observation. Sometimes the acute 
symptoms are preceded by indefinite pro- 
dromata. Sometimes the disease develops 
in two phases with a distinct pause be- 
tween, so that the patient, partially or 
even completely, recovers from the initial 
symptoms and then again becomes ill with 
accompanying paralysis. 

Among the initial symptoms are pain 
and a somewhat characteristic hyperes- 
thesia. Another series of initial symp- 
toms are meningitic irritation, pain in the 
back of the neck, and sometimes com- 
plete opisthotonos. In many cases the 
gastrointestinal symptoms, vomiting and 
diarrhea, are so severe that the disease 
assumes the stamp of an acute gastroin- 
testinal catarrh. During the first days it 
is not seldom that ''etention of urine is 
observed, but this disappears, without ex- 
ception, in a short time. Tne severity of 
the onset and of the initial symptoms can- 
not be dependec upon to determine the 
future course of the disease. 

The generally accepted opinion that the 
paralysis continues for life and that it is 
always attended by atrophy and the reac- 
tion of degeneration, is not true; on the 
contrary, there are many cases which only 
show a transient paralysis of several days 
to several weeks when the paralysis com- 
pletely disappears. 



SPINAL CORD, DISEASES OF (PRITCHARD). 



221 



The paralysis may involve the different 
muscle groups and may sometimes limit 
itself to a definite muscle group, e.g., the 
muscles of the neck. Sometimes most un- 
usual symptoms appear, e.g., the pupillary 
symptoms and optic neuritis. 

Sensibility to pressure over the nerves 
and muscles appears in a considerable 
number of cases. In rare cases there is 
a marked interference with sensibility, or 
partly a dissociated paralysis of sensation, 
or sometimes a complete anesthesia as a 
result of the changes in the anterior horns 
of the cord. Pretty constantly appears a 
diminution in the so-called electric sen- 
sibility, and, indeed, in many cases one 
can speak of a partial paralysis of sen- 
sibility or sensation. 

Concerning the tendon reflexes: The 
patellar reflex comes chiefly under con- 
sideration. These are by no means al- 
v^fays absent. An exaggeration of these 
reflexes may precede their complete dis- 
appearance. Incomplete paralysis of the 
leg with increase of the patellar reflex 
may remain. In affections of the upper 
part of the cord the patellar reflex may 
be increased as an indication that the 
white substance is also involved. 

Landry's Form. — In another series of 
cases the disease takes on an extensive 
course, and, indeed, the durcrent muscle 
groups may become involved, either in an 
ascending or descending manner. 

In case the muscles of respiration are 
involved, which means an affection of the 
respiratory center, the disease assumes 
the form of Landry's paralysis. Since the 
progress of the paralysis may be more 
easily followed in adults than in children, 
the erroneous reports, which are found 
generally in the literature, explain the 
different ages, as also the prognosis of 
poliomyelitis. Landry's paralysis in a 
child is generally diagnosed as poliomye- 
litis, while a fatal poliomyelitis in an 
adult is generally diagnosed as Landry's 
paralysis. 

Bulbar Form. — The bulbar and brain 
forms may occur together or separately. 
Most often in these forms facial paralysis 
appears, but frequently also an affection 
of the hypoglossus and eye muscles may 
occur. Sometimes the disease takes the 
form of an acute bulbar paralysis, but this 



form appears to be rare. Sometimes there 
exists an injury to the center of accom- 
modation, and thereby an ataxia of the 
cerebellar type or an exaggerated condi- 
tion of the reflexes may occur. 

Encephalitic Form. — Under this form 
are considered all cases of cerebral 
paralysis. 

Ataxic Form. — This form appears as a 
transient, acute ataxia, which most fre- 
quently resembles the cerebellar type. 

Polyneuritic Form. — When I mention 
this as a separate form I do so from 
purely practical grounds. During the epi- 
demic many cases appeared which, when 
grouped, were that of a distinct polyneu- 
ritis. To this form belong, first, cases 
which in a comparatively short time com- 
pletely recover, especially when they are 
accompanied by well-pronounced disturb- 
ance of sensation, such as pain and pares- 
thesia; second, cases which present such 
local symptoms as pain upon pressure on 
the nerves and muscles, and which inay 
be regarded as an affection of the periph- 
eral nerves; third, those cases under form 
5 mentioned as the ataxic form. The last 
two forms, 5 and 6, correspond to what 
is described in the literature as acute 
motor infectious neuritis. Clinically they 
cannot be differentiated from this form, 
but etiological!}' they are not identical. 
The pathological investigations have not 
been able to differentiate these forms, but 
since so many cases occurred during this 
epidemic of poliomyelitis, we must assume 
them to be of common origin and that 
the disease is really a transient poliomye- 
litis. That the differential diagnosis be- 
tween acute poliomyelitis and polj'neuritis 
under other conditions must first be con- 
sidered, is self-evident. 

Meningitic Form. — As before mentioned, 
in the initial stage and, indeed, not seldom 
meningitic irritation appears. This may 
be so severe and characteristic that one 
thinks he has to do with an acute menin- 
gitis. Later, however, the appearance of 
the paralysis usually makes the condition 
clear. The usual paral3-sis may, however, 
remain absent, so that the whole course 
is that of a meningitis serosa. This was 
demonstrated during the epidemic, clinic- 
ally as well as by autopsy. 

It is then natural to conclude that at 



222 



SPINAL CORD, DISEASES OF (PRITCHARD). 



least a part of the sporadic cases of se- 
rous meningitis results from the poison of 
the acute poliomyelitis. 

The opinion of several investigators, 
that there exists a relation between the 
etiology of epidemic cerebrospinal menin- 
gitis and infantile paralysis, is, in my 
opinion, not sound. The difference in the 
whole course of the diseases, in the in- 
dividual symptoms, as well as in the an- 
atomical changes, is so great that we 
are justified in regarding them as two 
distinct diseases. 

Abortive Form. — Frequently other cases 
occurred in the vicinity of the typical 
cases of poliomyelitis, which, in general, 
gave only the picture of a general infec- 
tion, but of which the symptoms corre- 
spond to the initial symptoms of the 
typical ones. Such cases must be termed 
abortive forms. One can, however, differ- 
entiate various types of the abortive 
form : — 

(a) Cases which run the course of a 
general infection. 

(b) Cases in which there is some men- 
ingitic irritation. 

(c) Cases in which the painful symp- 
toms are well pronounced (influenza 
type). 

(d) Cases in which the gastrointestinal 
symptoms are especially marked. 

How far anatomical changes of even 
the slightest degree are present in these 
abortive cases is not, with any certainty, 
decided. 

DIAGNOSIS.— An early diagnosis, 
i.e., before the onset of paralysis, 
would prove of service as regards 
prophylactic measures, were any such 

available. 

We must accustom ourselves to 
keep the possibilities of poliomyelitis 
more frequently in view. Any case 
of acute febrile disease, especially in 
children, which is characterized by a 
general hyperesthesia of the skin 
with a tendency to profuse sweat- 
ing, absence of leucocytosis, weak- 
ness, and decrease of the muscle 
tonus in certain muscle groups with 
diminished tendon reflexes should 
strongly arouse suspicion. Starck 
(Med. Klinik, Dec. 22, 1912). 



The prodromal symptoms enumer- 
ated under the foregoing heading are 
important in this connection: Irri- 
tability and restlessness several days 
before other symptoms appear ; head- 
ache, vomiting, then slight spinal 
rigidity with occipital headache and 
backache, particularly along the 
spine when any attempt at rotation 
of the trunk is made; marked and 
persistent asthenia; rapid and weak 
pulse; hyperesthesia; pains in the 
limbs with exaggerated patellar re- 
flex — are suggestive in the absence of 
an epidemic, and especially so when 
cne prevails. 

In some forms of poliomyelitis, the 
brain, medulla, and pons are specially 
involved, leaving the cord, for the 
most part, unaffected permanently, — 
really cases of polioencephalitis. 
Some of these cases closely resemble 
cerebrospinal meningitis. The differ- 
ential points are: (1) In poliomye- 
litis there is a short preliminary 
period in which patient, having had 
high fever, continues to be about; not 
in meningitis. (2) Increasing sopor, 
extending over days, in poliomyelitis; 
this is quite unlike the onset of cere- 
brospinal meningitis. Other cases 
closely simulate tuberculous menin- 
gitis. Differential points: (1) In 
polioencephalitis, onset is sudden; in 
tuberculous meningitis, gradual. (2) 
In former affections, there occurs a 
gradual diminution of the prelimi- 
nary sopor, and in a week or two pa- 
tient is brighter; in tuberculous men- 
ingitis sopor deepens into coma. 
Koplik (Amer. Jour. Med. Sci., June, 
1911). 

Hitherto unobserved preparalytic 
symptom consisting of a peculiar 
twitching, tremulous or convulsive 
movement of certain groups of mus- 
cles, lasting from a very few seconds 
to somewhat less than a minute. The 
amplitude of vibration is greater than 
in a tremor, not so constant. Colliver 
(Cal. State Jour. Med., Nov., 1913). 



SPINAL CORD, DISEASES OF (PRITCHARD). 



223 



Congestion of the throat is almost 
constant during the early acute stage. 
It is usually limited to the faucial 
mucosa and the pharynx, while the 
soft palate assumes a deep red color 
and often, in addition, a distinct vio- 
laceous tinge. The latter, when pro- 
nounced, is somewhat distinctive. 
Regan (Arch, of Pediat., Dec, 1917). 

Tuberculous meningitis may be 
simulated. The spinal fluid in this 
case may contain tubercle bacilli, and 
injection of it into a guinea-pig may 
facilitate differentiation. There may 
be an evident primary focus, and also 
choroidal tubercles. Syphilitic menin- 
gitis is determined by a positive Was- 
sermann. Other diseases to be ex- 
cluded are gastro-intestinal disturb-' 
ances, rickets, scurvy, acute arthritis, 
and tuberculosis of the hip. Tum- 
powsky (111. Med. Jour., Apr., 1918). 
Report of experiments indicating 
that the virus is regularly present in 
the nasopharynx in the first days of 
illness and decreases relatively quickly 
as the disease progresses, except in 
rare instances; and that it is unusual 
for a carrier state to be developed. 
Flexner and Amoss (Jour, of Exper. 
Med., Apr., 1919). 

In several personal cases and others 
observed by colleagues in a recent 
outbreak, all had at the outset a catar- 
rhal inflammation of the nose and 
throat and but few gastro-intestinal 
signs. Abrahamson (N. Y. Med. Jour., 
April 20, 1921). 
A lumbar puncture made at this 
time may confirm the diagnosis by 
demonstrating a shght opalescence or 
milkiness in the spinal fluid with- 
drawn, which opalescence indicates 
the early appearance of paralytic phe- 
nomena. It also contains, after a pre- 
liminary fall, an excess of leucocytes, 
mainly lymphocytes, tending to reach 
the maximum when paralysis impends. 
The value of lumbar puncture as 
an aid in diagnosis between cases of 
acute cerebrospinal meningitis and 
acute poliomyelitis of the meningeal 
type is undoubted. In the former 



the fluid shows marked turbidity, fre- 
quently coarse, purulent clot forma- 
tion, a great excess of albumin, ab- 
sence of dextrose, and the meningo- 
coccus. Forbes (Lancet, Nov. 18, 1911). 

Increase of pressure is the most 
persistent of the changes in the spinal 
fluid in poliomyelitis, and does not 
disappear for several months. After 
the tenth day it is present in nearly 
100 per cent, of cases. Of the fluids 
examined, 93 per cent, showed an in- 
crease in the globulin content and 86 
per cent., a pleocytosis. Lympho- 
cytes predominated. Larkin and Corn- 
wall (Arch, of Pediatr., Aug., 1918). 

The history of the acute or febrile 
stage is of import, especially in ex- 
cluding cerebral meningitis and the 
cerebral palsies of childhood. In polio- 
myelitis there are few irritative symp- 
toms. Convulsions may occur, but 
the patient does not develop epilepsy 
or mental enfeeblement. Epilepsy, on 
the other hand, is often a part of the 
symptom-picture in the cerebral pal- 
sies and mental impairment in some 
degree almost invariably present. 
The type of the paralysis in the two 
is exactly opposite. In poliomyelitis 
the paralysis is flaccid, the reflexes 
are lost, the muscles atrophy, the 
muscles affected are functionally as- 
sociated, and a monoplegia is the rule 
as regards distribution. In the true 
cerebral palsies the paralysis is spas- 
tic in type, with exaggerated reflexes; 
no wasting, although arrest of de- 
velopment may result ; the paralysis 
is of muscles anatomically associated ; 
the distribution is usually hemiplegic, 
monoplegias being rare. In cerebral 
palsies, too, the cranial nerves, par- 
ticularly the facial, are often afifected 
and the mind is almost invariably im- 
paired. Finally, there are no elec- 
trical changes characteristic of the 
cerebral palsies. 



224 



SPINAL CORD, DISEASES OF (PRITCHARD). 



From other forms of myelitis infan- 
tile spinal paralysis is to be distin- 
guished chiefly by the frequent ab- 
sence in the latter afifection of sensory 
symptoms, of sphincter involvement, 
of bed-sores, of spastic or semispastic 
phenomena. Palsies from peripheral 
neuritis due to trauma, including so- 
called birth-palsies caused l)y obstet- 
rical forceps or injury in delivery, are 
often difficult to distinguish from 
poliomyelitis. The history of injury 
to the arm or shoulder and the an- 
atomical distribution of the paralysis 
are points of differential value. In 
neuritis of this type sensor}^ disturb- 
ances are not conspicuous, as a rule, 
but may be present. The history as 
to mode of onset and progress serves 
to distinguish poliomyelitis anterior 
acuta from the pure muscular atro- 
phies. Differentiation from cerebro- 
spinal meningitis is at times, espe- 
cially in endemic outbreaks of either 
disease, exceedingly difficult. Lab- 
oratory methods in the bacteriolog- 
ical examination are in such cases 
imperative as the only accurate method 
by which to determine the identity of 



a given case. 



ETIOLOGY. — The pathogenic 
agent of poliocerebromyelitis has been 
found by Flexner to be an exceed- 
ingly minute organism, emulsions of 
a virulent spinal cord being still in- 
fective after filtration through Cham- 
berland filters. That it is a living 
organism is shown by the fact that 
it undergoes reproduction in the body 
of an inoculated animal, a small 
amount of emulsion of the spinal cord 
of a victim of the disease injected 
into a monkey being sufficient to 
cause it after a period of incubation 
of 5 to 46 days. It has not been iso- 
lated in pure culture. 



It is not only constantly present in 
the cerebrospinal system, but also in 
the mucosa of the nasal cavities and 
pharynx, the salivary, mesenteric, 
and lymph glands after inoculation, 
and also in the spinal fluid, and in 
small quantity in the blood. Animals 
other than the monkey, with the ex- 
ception of certain breeds of rabbits, 
do not appear susceptible to inocula- 
tion. Monkeys that recover from the 
infection show a definite immunity to- 
reinoculation, while their blood-serum 
deprives an emulsion of virulent 
spinal cord of all pathogenic power. 

The organism probably penetrates 
the central nervous system after en- 
tering the body by way of the naso- 
pharynx or intestinal tract, or both. 
The secretions of the nose and throat 
are, therefore, regarded as infectious 
and capable of disseminating the dis- 
ease by direct contact. Hence, the 
fact that the patient should be iso- 
lated and kept from school at least 
three weeks after convalescence. See 
Prophylaxis below. 

The physical properties of the virus 
adapt it well for conveyance to the 
nose and throat. Being contained in 
their secretions, it is readily dis- 
tributed by coughing, sneezing, kiss- 
ing and b}^ means of fingers and 
articles contaminated with these se- 
cretions, as well as with the intes- 
tinal discharges. Moreover, as the 
virus is thrown oE from the body 
mingled with the secretions, it with- 
stands for a long time even the high- 
est summer temperatures, complete 
drying, and even the action of weak 
chemicals, such as glycerin and car- 
bolic acid, which destroy ordinary 
bacteria. 

Hence mere drying of the secre- 
tions is no protection; on the con- 
trary, as the dried secretions may be 
converted into dust which is breathed 
into the nose and throat, they be- 



SPINAL CORD, DISEASES OF (PRITCHARD). 



225 



come a potential source of infection. 
The survival of the virus in the se- 
cretions is favored by weak daylight 
and darkness, and hindered by bright 
daylight and sunshine. It is readily 
destroyed by exposure to sunlight. 
Simon Flexner (Address, New York, 
July 13, 1916). 

Ninety per cent, of the acute cases 
occur within the first decade of life 
and more than half of all cases within 
the first three years of life. Among 
children the two sexes seem about 
equally susceptible. Among- adults 
it is comparatively rare in the female. 
The disease is no respecter of caste 



(giant cells) of the anterior horns. 
This occurs as the result of an in- 
flammatory myelitic process dis- 
seminated more or less extensively 
throughout the cord, but chiefly in 
the anterior gray matter, induced by 
the Flexner micro-organism, the me- 
dium of invasion being the branches 
of the anterior spinal artery. In the 
Striimpell and Wernicke types the 
cortical and basal nuclei or neurons 
are involved. The cells of the lower 
dorsal and midcervical segments are 
most frequently afifected. The ante- 
rior nerve-roots are also afifected sec- 



or class, nor does it manifest any ondarily with degenerative changes. 



special racial proclivities, though the 
negro is comparatively exempt and 
the disease is more common in cen- 
ters of dense population than in rural 
districts. Poliomyelitis is often a 
sequel to the febrile infections of 
childhood, especially scarlet fever, 
measles, and diphtheria. In this re- 
spect, as well as others, its etiology 



and this is true of the muscles to 
which the affected nerves are distrib- 
uted. The atrophied muscles show 
a distinct diminution in the size and 
number of fibers, the normal tissue 
being replaced by fat and connective 
tissue. 

PROGNOSIS.— To approximate 
idurinof the acute febrile stage the 



is quite similar to that of epidemic extent or degree and the distribution 
and sporadic cerebrospinal menin- of the final more or less permanent 
gitis. Poliomyelitis may also occur paralysis there is no positive guide, 
as an epidemic. but the severity of the constitutional 
In not a few instances trauma ap- disturbance, including temperature, 
pears as the exciting cause; exposure is sometimes an index. Occasionally 
to extreme cold or to excessive or after the constitutional disturbance 
violent exercise may superinduce the subsides, the loss of power may re- 
disease. The season has its influence, main rather widely distributed. In 
many more cases occurring in sum- such instances the electrical response 
mer than in winter. This is espe- affords information. If the quantita- 



cially noticeable in seasons of pro- 
longed excessive heat. Among adults 
violent exercise, exposure, trauma. 



tive response grows less or the quali- 
tative change greater from day to day 
in certain muscles or a limb, just in 



debilitating 



excesses, and syphilis proportion is there likely to be a per- 

are recognized as potent factors, manent residual paralysis. In all 

Heredity is not a factor. cases some permanent paralysis will 

PATHOLOGY. — The essential le- remain, but it may be six months 

sion in acute anterior poliomyelitis is from the onset before the limits of 

a trophic destruction, more or less this paralysis can be determined. The 

complete, of the larger ganglion-cells patient is handicapped physically in 

8—15 



226 



SPINAL CORD, DISEASES OF (PRITCHARD). 



after-life to a greater or less extent, 
but never mentally. The prognosis 
depends largely upon the ability of 
the parent to carry out instructions 
in faithful, patient, persistent treat- 
ment. Recoveries range from 7.1 per 
cent. (New York epidemic) to 19.2 
per cent. (Minnesota epidemic). 

In poliomyelitis proper the prog- 
nosis as regards life is almost invari- 
ably good. In the polioencephalitic 
type a fatal result has been frequently 
noted, and this is true of certain en- 
demic outbreaks, a variable virulence 
in the micro-organism afifording the 
probable explanation. 

The prognosis as to life is good in 
sporadic cases; in epidemics the mor- 
tality is frequently 12 per cent., and 
in some may rise as high as 40 per 
cent. Hochhaus (Miinch. med. Woch., 
Nov. 16, 1909). 

PROPHYLAXIS. — Flexner holds 
that the United States has suffered 
disproportionately and more severely 
than Europe in its epidemics of polio- 
myelitis because the disease was 
often unrecognized, and there were 
no authoritative sanitary regula- 
tions to enforce quarantine. Most 
attention should be paid to preven- 
tion. Human transmission, both by 
those actively infected and those who 
are about the ill, occurs frequently. 
Hence there must be quarantine of 
the sick and of those in attendance on 
the sick. Cases of long persistence of 
the active virus in the monkey are 
cases of chronic bacteria carriers. A 
period of isolation of three to four 
weeks is necessary even in ordinary 
cases. The nasal and buccal secre- 
tions of those affected with polio- 
myelitis must be especially well cared 
for, as in them is probably the chief 
source of infection, although all the 



excretions must also be asepticized. 
Domestic animals may serve as res- 
ervoirs for the virus. Flies may 
harbor the virus on their bodies or 
in their viscera. Recovery from the 
disease is effected by means of im- 
munizing principles in the blood. 
Sera obtained from animals subjected 
to injections of spinal cord and brain 
of monkeys containing the living 
virus are relatively weak in anti- 
bodies, and will be of little aid in 
cases of developed poliomyelitis in 
human beings. The only drug rec- 
ommended is hexamethylenamine. 

Once in the air the virus may be 
disseminated in various ways, by di- 
rect contact with clothing, by the 
wind, and by water. As prophylactic 
measures, washing down and oiling 
the streets, antiseptic scrubbings of 
rooms, spraying the nasopharynx 
with hydrogen peroxide in persons 
exposed, a .«trict quarantine for at 
least two months, prohibition of 
bathing in stagnant water in a neigh- 
borhood where a case occurs, as well 
as of playing around sand-heaps, and 
thorough disinfection of domestic 
animals are recommended. M. Neu- 
staedter (Jour. Amer. Med. Assoc, 
■ Sept. 7, 1912). 

The writer emphasizes the need 
for greater care in the prevention of 
the spread of the disease by the use 
of (1) dilute hydrogen peroxide or 5 
per cent, menthol nasal irrigation for 
those exposed; (2) disinfection of 
the patient's stools and urine; and 
(3) isolation of the patient for six 
weeks and of other members of the 
household for three weeks. G. W. 
Howland (Can. Jour. Med. and Surg., 
xxxvii, 52, 1915). 

Practical demonstration of the fact 
that the active virus of poliomyelitis 
may occur in rectal washings ob- 
tained from a patient fourteen days 
after the beginning of the paralysis. 
Since the virus may leave the body 
from the rectum, as well as from 



SPINAL CORD, DISEASES OF (PRITCHARD). 



227 



the nose and mouth, precautions 
should be taken in the care of polio- 
myelitis patients to prevent infection 
from feces and soiled bedding. W. 
A. Sawyer (Amer. Jour. Trop. Dis. 
and Prevent. Med., Sept., 1915). 

The chief means by ivhicJi the secre- 
tions of the nose and throat are dis- 
seminated is through the act of kissing, 
coughing, or sneezing. Hence during 
the prevalence of an epidemic of in- 
fantile paralysis, care should be exer- 
cised to restrict the distribution as 
far as possible through these com- 
mon means. Habits of self-denial, 
care and cleanliness and considera- 
tion for the public welfare can be 
made to go very far in limiting the 
dangers from these sources. 

Moreover, since the disease at- 
tacks by preference young children 
and infants, in whom the secretions 
from the nose and mouth are wiped 
away by mother or nurse, the fingers 
of these persons readily become con- 
taminated. Through attentions on 
other children or the preparation of 
food which may be contaminated, the 
virus may thus be conveyed from the 
sick to the healthy. 

The conditions which obtain in a 
household in which a mother waits 
on the sick child and attends the 
other children are directly contrasted 
with those existing in a well-ordered 
hospital; the one is a menace, the 
other a protection to the community. 
Moreover, in homes the practice of 
carrying small children about and 
comforting them is the rule, through 
which not only the hands, but other 
parts of the body and the clothing of 
parents may become contaminated. 

Flies also often collect about the 
nose and mouth of patients ill of in- 
fantile paralysis and feed on the se- 
cretions, and they even gain access 
to the discharges fronx the intestines 
in homes unprotected by screens. 
This fact relates to the domestic fly, 
which, becoming grossly contaminated 
with the virus, may deposit it on the 
nose and mouth of healthy persons, or 
upon food or eating utensils. To what 



extent the biting stable-fly is to be 
incriminated as a carrier of infection 
is doubtful; but we already know 
enough to wish to exclude from the 
sick, and hence from menacing the 
well, all objectionable household in- 
sects. 

Food exposed to sale may become 
contaminated by flics or from fingers 
whicli have been in contact with secre- 
tions containing the virus; hence food 
should not be exposed in shops and no 
person in attendance upon a case of 
infantile paralysis should be permitted 
to handle food for sale to the general 
public. 

Protection to the public can be best 
secured through the discovery and iso- 
lation of those ill of the disease, and 
the sanitary control of those persons 
who have associated with the sick and 
whose business calls them away from 
home. Both these conditions can be 
secured without too great interfer- 
ence with the comforts and the rights 
of individuals. 

Where homes are not suited to the 
care of the ill so that other children 
in the same or adjacent families are 
exposed, the parents should consent 
to removal to hospital in the interest 
of the sick child itself, as well as in 
the interest of other children. But 
this removal or care must include 
not only the frankly paralyzed cases, 
but also the other forms of the 
disease. 

In the event of doubtful diagnosis, 
the aid of the laboratory is to be 
sought, since even in the mildest 
cases changes will be detected in the 
cerebrospinal fluid removed by lum- 
bar puncture. If the efifort is to be 
made to control the disease by isola- 
tion and segregation of the ill, then 
these means must be made as inclu- 
sive as possible. It is obvious that 
in certain homes isolation can be 
carried out as effectively as in hos- 
pitals. Simon Flcxncr (Address, New 
York, July 13, 1916). 

TREATMENT.— No material proo-- 
rcss has of late been made in the 
treatment of the disease. 



228 



SPINAL CORD, DISEASES OF (PRITCHARD). 



During the febrile stage the treat- 
ment is that for all forms of acute 
myelitis, including absolute quiet and 
rest, ice-bags or counterirritation to 
the spine, laxatives, and a non-stimu- 
lating, easily digested diet. To these 
measures should be added, if there is 
much fever, antipyretics, such as phe- 
nacetin or other coal-tar derivatives. 
It is customary to use ergot in Yz- 
dram (2 Gm.) doses or less, with or 
without bromide of potassium, and 
no liarni is likely to follow its em- 
ployment. The salicylate of soda has 
been employed with some advantage 
in epidemics of the disease, and its 
use seems rational. Administration of 
hexamethylenamine in full doses has 
been advised throughout the acute 
stage. In Flexner's experiments on 
monkeys, however, the drug proved ef- 
fective only very early in the course of 
the inoculation, and in only a part of 
the animals treated. The dose should 
be 2 grains (0.13 Gm.) every six hours 
for a child of 2 or 3 years of age; 3 
grains (0.2 Gm.) at 6 to 10 years, and 
5 grains (0.3 Gm.) for adults. 

Among 11 cases treated with ad- 
renalin, as recommended by Meltzer, 
there were 18 deaths, of which but 5, 
or 6.9 per cent., are considered fail- 
ures of the adrenalin treatment. The 
bottle of 1:1000 solution was first 
placed in a bath of boiling water to 
drive off the chloretone. Spinal punc- 
ture was made between the fourth 
and fifth lumbar vertebrae, intraspinal 
pressure relieved, and 2 c.c. (32 min- 
ims) of the adrenalin solution in- 
jected. This was repeated every 6 
hours day and night until the tem- 
perature was normal. P. M. Lewis 
(Med. Rec, Sept. 23, 1916). 

In epidemics, as a measure of pro- 
phylaxis, careful attention should be 
given to the hygiene of the naso- 
pharynx, intranasal antiseptic solu- 



tions being indicated. A 1 per cent. 

hydrogen dioxide solution should be 

used as spray and gargle by the 

patient and the members of his 

family. Argyrol (25 per cent.), pro- 

targol, chinosol (1 : 2000), or colloidal 

silver are also available for this. 

Efforts to immunize by bacterial 

sera have not been as yet successfully 

perfected, although Flexner's work in 

this direction has seemed to promise 

much for the future. 

The writers deem it established for 
monkeys, and probable for man, that 
intraspinal injection of immune serum 
in poliomyelitis is curative. Flexner 
and Amoss (Jour, of Exper. Med., 
Apr., 1917). 

Report of 26 cases treated with 
large amounts of serum obtained from 
persons recently recovered from ' 
poliomyelitis. Apparently the best 
results were obtained in cases treated 
within 30 hours. Amoss and Chesney 
(Jour, of Exp. Med., 25, 581, 1917). 

An immune serum of high titer was 
prepared by repeated inoculation of 
the horse with the coccus of anterior 
poliomyelitis and used in 159 cases. 
The mortality was 12 per cent., as 
against 32 per cent, in the untreated. 
Ten patients were treated in the pre- 
paralytic stage, and all recovered 
without paralysis. The serum arrests 
the progress of paralysis when de- 
veloping. It was given intraspinally 
by the gravitj' method after with- 
drawal of spinal fluid, the dose being 
5 to 10 c.c. for a child. Simultane- 
ously from 10 to 30 c.c. were given 
intravenously. The injections were 
repeated at intervals of twenty-four 
hours. J. W. Nuzum and R. G. Willy 
(Jour. Amer. Med. Assoc, Oct 13, 
1917). 

Treatment of poliomj'elitis with 
immune horse serum applied in 58 
cases. Altogether, 94 intravenous in- 
jections were made. In no instance 
was a primary toxic action noticeable, 
and in only 6 was there later evidence 
of serum disease. Ten patients died, 



SPINAL CORD, DISEASES OF (PRITCHARD). 



229 



a mortality of 17 per cent. Exclud- 
ing 7 already moribund, there were 
but 3 deaths. Of 23 untreated pa- 
tients, 9 died. Paralysis never de- 
veloped when treatment was begun 
before its onset. No extension of ex- 
isting paralysis occurred. Rosenow 
(Jour, of Infect. Dis., Apr., 1918). 

The antistreptococcic serum of 
Nuzum and Willy has failed to show 
in the monkey neutralizing or thera- 
peutic power when applied by the 
writers' methods against small doses 
of the virus of poliomyelitis. Under 
the same conditions the serum of 
monkeys recovered from experimen- 
tal poliomyelitis proved neutralizing 
and protective. Amossi and Eberson 
(Jour, of Exper. Med., Sept., 1918). 

The writer applied the therapeutic 
test devised by Amoss and Eberson 
to fresh samples of immune horse 
serum prepared by injections of the 
poliomyelitic coccus in the horse. 
Three monkeys were completely pro- 
tected while the fourth developed 
mild symptoins and recovered com- 
pletely. The control monkeys re- 
ceiving normal horse serum all died. 
Fresh immune horse serum protected 
perfectly against infection, while 
pooled immune monkey serum served 
only to delay the onset of a fatal in- 
fection. Nuzum (Jour, of Infect. Dis., 
Sept., 1918). 

For the permanent residual paral- 
ysis our most reliable therapeutic re- 
sources consist of electricity, mas- 
sage, and exercise of the parts through 
the assistance of various mechanical 
appliances to be appropriately de- 
vised by the orthopedist. Both cur- 
rents should be employed. In using 
galvanism one electrode, a large flat 
pad, should be placed over the spine 
at the level affected, the other on the 
limb paralyzed. Not more than 3 to 
5 milliamperes should be used at first. 
As the child becomes accustomed to 
it, the current-strength may be grad- 
ually increased. The seance should 



last twenty minutes daily, and should 
be followed by an application of the 
faradic current to the limb itself. The 
current here should be strong enough 
to produce gentle contractions. If 
there is no response to faradism ex- 
cept with painfully strong currents, 
the interrupted galvanic current may 
be used in the same way. As much 
as possible of the affected muscle 
should be included in the circuit. 

Massage should be given, prefer- 
ably by one qualified for the work, 
though, if an expert be not available, 
simple rubbing is of at least some 
service in stimulating the circulation 
and local nutrition. Strychnine inter- 
nally is at times of apparent value. 
The amount should vary with the 
age, of course, but much larger doses 
than are ordinarily prescribed are in- 
dicated. Such large doses may be 
quite safely reached by a gradual in- 
crease. Splints, braces, and other ap- 
pliances serve a useful purpose in 
preventing crippling contractions and 
unsightly deformities. A flaccid leg 
may be supported by a brace so as to 
become useful in walking, which in 
itself is a valuable therapeutic aid. 
Velocipedes, tricycles, and other sim- 
ilar machines are often of much 
service. 

The employment of re-educational 
and developmental exercises with 
muscle training, direct or vicarious, 
should be much more extensively and 
hopefully employed. Much more is 
to be accomplished remedially by 
such methods than by the prolonged 
employment of fixation apparatus, 
l)races, and dther su])portive devices. 

Operative Treatment. — Consider- 
able work in this direction has been 
done in recent years. Besides efforts 
to correct deformity and improve 



230 



SPINAL CORD, DISEASES OF (PRITCHARD). 



muscular function referred to above, 
tendon transplantation, insertion of 
bone, insertion of periosteum, ar- 
throdesis or the production of arti- 
ficial ankylosis and other operations 
have been employed. As these be- 
lono- to the held of the orthopedic 
surgeon, a recently published report 
by Dr. R. Tunstall Taylor {Nczv York 
Medical Journal, January 29, 1916) is 
submitted : — 

Tenotomy and Myotomy. — Orthopedists 
daily now employ them in correcting de- 
formities by severing the overactive mus- 
cles and lengthening them thereby; this 
overactivity is due to a paretic condition 
in the antagonist or antagonistic group as 
explained by Seligmiiller's theories. These 
operations are of distinct benefit, in that 
they not only restore the normal align- 
ment in the members, but relieve the re- 
maining weakened living muscular fibers 
in the paretic muscle from overstrain, 
which in itself is a detriment. As a rule, 
some mechanical device to prevent recon- 
tracture of the overstrong muscle is re- 
quired in the after-treatment of all cases. 
Tendon shortening by taking a tuck in 
it by suture, tying, or removal of a sec- 
tion has been done by various surgeons 
in the past. 

Tendon lengthening has been accom- 
plished more often by tenotomy subcu- 
taneously within the sheath, and lengthen- 
ing has occurred by organization of the 
plastic exudate between the severed ends. 
Some few authorities prefer lengthening 
the tendon by obUque section and suture 
through an open' incision. Again, others 
prefer to lengthen by the Bayer Z section 
and then stretching. Again we find some, 
instead of cutting the tendon transversely, 
cut it from below upward and forward 
through the width of the tendon to get 
a broader surface for sewing. 

Tenodesis was a procedure advocated 
by Hoffa and extensively used by him, of 
converting the tendons around a joint 
into ligaments by sewing them above and 
below a joint, to increase its stability 
when flail-like and to restore proper 
alignment and balance when distorted. 



Gallie's recently presented operation is 
akin to Hoffa's tenodesis in that he en- 
deavors to secure more thorough joint 
fixation by using a whole or a part of a 
tendon near the ankle to produce a ten- 
don fixation into the bone, which he has 
grooved with a gouge to sufficient depth 
to suture and bury the tendon and to 
cover it with the incised and elevated 
periosteum. 

Extra-articular silk ligaments, chiefly to 
support a flail ankle, knee, or shoulder 
have been advocated by Lange and Alli- 
son. The former has preferred silk liga- 
ments to arthrodesis since 1903 and intro- 
duces from 6 to 8 strong silk threads su- 
tured to the periosteum of the scaphoid 
and tibia and cuboid and fibula, having 
been passed through the adipose tissue 
from point to point. The upper point of 
attachment is 5 cm. above the ankle-joint. 
Allison uses the silk as a stirrup. With 
a drill having an eyelet which he threads, 
he passes the silk through the anterior 
tarsal bones from side to side of the foot, 
then threads a probe, which he passes 
under the annular ligament up to the 
crest of the tibia, where he makes an in- 
cision and sutures the two ends to the 
periosteum. Similarly, he threads the os 
calcis and passes the ends up for suture 
in the posterior aspect of the tibial perios- 
teum. 

Intra-articular Silk Ligaments.— Bartow 
and Plummer describe artificial ligaments 
of silk which are both intraosseous and 
intra-articular, passed into and through 
joints in the desired direction to restrict 
or limit motion, to be used exclusively in 
flail joints. It is especially adapted for 
use at the knee, ankle, and shoulder, using 
14-20 Corticelli silk. Allied somewhat, 
only so far as the effect obtained is con- 
cerned, is the operation of Robert Jones 
for flail elbow, where we have a useful 
band which is valueless when the arm 
hangs at the side. He removes a dia- 
mond-shaped flap of skin from the front 
of the elbow, of sufficient size so that the 
two equal triangles which go to make up 
the diamond when approximated and su- 
tured, will hold the forearm at 40 degrees 
with the arm, the most useful angle. 

Arthrodesis for flail joints was described 
at length by Townsend and Goldthwait in 



SPINAL CORD, DISEASES OF (PRITCHARD). 



231 



excellent articles which will be found in 
the Transactions of the American Ortho- 
pedic Association. This procedure, espe- 
cially for the ankle, has many warm ad- 
vocates, as it enables the paralytic in 
many cases to do without a brace. It is 
employed also at the shoulder in deltoid 
paralysis and at the hip and knee rarely; 
never at the hip, knee, and ankle of 
the same subject. H. Augustus Wilson 
strongly advocates this procedure. 

Articular Transposition.— Gwilym Davis 
has devised an ingenious and efficient op- 
eration for paralytic talipes calcaneus in 
which he makes a transverse horizontal 
section through the os calcis just below 
the articular surface adjacent to the as- 
tragalus. He then slides the heel back 
and the tibia, fibula, and astragalus for- 
ward, so that the weight comes upon the 
anterior portion of the os calcis, and cal- 
caneus is impossible. This procedure I 
have classified as "articular transposition." 
His results are excellent. 

Astragalectomy. — Whitman has been 
the author and chief advocate of astrag- 
alectomy for talipes calcaneus. After 
removal he slides the tibia and fibula for- 
ward, and the recurrence of calcaneus is 
practically prevented as in Davis's opera- 
tion. The mutilation, prevention of other 
motions, and shortening of the limb are 
its chief objections, but the gait se- 
cured is excellent and the deformity is 
corrected. 

Nerve Anastomosis. — This procedure 
has been successful in secondary suture 
after traumatic section of nerves, and in 
facial paralysis. Spitzy was successful ex- 
perimentally in dogs' legs, in anastomos- 
ing nerves both centrally and peripherally, 
and Howell anastomosed flexor nerves 
into extensor and znce versa in dogs' legs, 
but neuroplasty has failed to meet expec- 
tations in anterior poliomyelitis, when the 
peripheral end of a paralyzed nerve was 
sutured into a functioning nerve or a slip 
from a functioning nerve was attached to 
a paralyzed nerve. There is evidently a 
general impairment in all the nerves in a 
partially paralyzed extremity, and a nerve 
anastomosis is like taxing an already weak 
and run-down battery with more work. 

Tendon Transplantation on Tendon. — 
It consists in the attachment of the distal 



tendon of the weakened muscle to one 
still alive and functionally active, to help 
restore support and use to the paralyzed 
tendon, but only in rare instances have 
these cases yielded results which enabled 
the patient to do without artificial sup- 
port. Dane's statistics of 50 cases from 
the Children's Hospital, Boston, were dis- 
couraging, as were reports from elsewhere 
in this country and abroad. 

Tendon Transplantation to Periosteum. 
— Since 1899, by means of the new method 
of Lange, as it is called, in contradistinc- 
tion to the older method of Nicoladoni, 
we suture the tendon to the periosteum 
or a silk prolongation of the tendon to 
the periosteum, or actually pass the ten- 
don through a bony canal, or sew it to 
the bone, or reduplicate it on and suture 
it by Ryerson's method to itself. This 
seems to have maintained the desired 
muscular tension much better and to have 
accomplished the aim we have in view 
more satisfactorily in the writer's hands, 
and, as reported, by HofTa, H. Augustus 
Wilson, Dane, Le Breton, and others. 

Elongation of short tendons by means 
of silk sutures — preferably white subli- 
mated — coated with paraffin, and giving 
these a periosteal attachment, has also 
yielded good results in my experience. 
Auger first used silk to lengthen tendons 
in 1875, to which Lange calls our atten- 
tion, but Lange popularized its use. 

The following operation has been con- 
stantly employed by me since 1909 and 
in some 300 cases of leg and foot parlysis: 
The tendon must be carried straight from 
the origin to the new insertion to gain 
the greatest mechanical efficiency, and the 
annular ligament must be employed when 
possible to take up any slack in the new 
order of things. The tendon is more se- 
curely fixed if sutured to a notch in the 
bone, retained in a fixed dressing for 4 
months, and without weight bearing for 
2 months. 

MYELITIS. 

SYNONYMS.— Inflammation of 
the spinal cord ; softening of the 
spinal cord. 

DEFINITION.— Myelitis is an in- 
flammation, localized or general, with 



232 



SPINAL CORD, DISEASES OF (PRITCHARD). 



secondary softening or sclerosis of 
the spinal cord, with irritative and 
paralytic motor and sensory as well 
as special symptoms, varying- in char- 
acter and distribution with the locali- 
zation and degree of the morbid pro- 
cess at different levels or areas of the 
cord. ]\Iany varieties are recognized. 
The anatomical division includes the 
cervical, dorsal, and lumbar varieties ; 
the transverse (imperfect or com- 
plete) ; the diffuse, or disseminated; 
the focal ; the central ; and the mar- 
ginal. The last mentioned is fre- 
quently associated with and often 
dependent upon a meningitis, the re- 
sultant condition being known as 
meningomyelitis. The etiological di- 
vision includes at least three varieties 
of importance : the traumatic, the 
syphilitic, and the tubercular. The 
terms acute, subacute, and chronic 
appear in the literature, although 
Striimpell and others dispute the ex- 
istence of a primary chronic myelitis. 
The type of all forms is acute trans- 
verse myelitis. 

SYMPTOMS.— The disease may 
begin abruptly, subacutely, or very 
gradually. When the onset is abrupt 
a chill may occur, followed by fever, 
the temperature ranging from 101° to 
104° F. (38.3° to 40° C), occasion- 
ally higher. In children the onset 
may be attended with convulsions; 
aside from the general malaise and 
fever, the constitutional disturbance 
may be slight. 

The essential nervous symptoms 
are usually irritative at first, although 
motor and sensory paralysis may be 
present from the start. These nerv- 
ous symptoms vary widely with the 
locality and extent of the myelitic 
process, imperatively necessitating a 
certain degree of familiarity with the 



topographical anatomy and functional 
localization of the cord. The dorsal 
region is most frequently affected in 
the focal disease. Among the irrita- 
tive symptoms hyperalgesia and hy- 
perestliesia are common. The patient 
may complain, sometimes emphatic- 
ally, of pain in the back and legs. 
Quite often the sensation is that of 
a tired aching in the limbs, as from 
excessive fatigue. If up and walking 
about, the legs are lifted wearily and 
the patient refers to them as being 
vveighted with lead. There is a sub- 
jective numbness, or various pares- 
thesiae may be mentioned. The blad- 
der is disturbed in function. There 
is retention, or the urine may dribble 
involuntarily. The bowels are usu- 
ally obstinately constipated ; less fre- 
quently there is incontinence of feces. 
Sexual power is lost or there may be 
persistent priapism. A feeling as of 
a band or belt encircling the hips, the 
waist, or the chest may be present. 
This is the so-called ccinture, or gir- 
dle symptom, and is quite constant in 
myelitis. The level of the ccinture 
feeling is a guide to the level of the 
cord-lesion. If the disease is of the 
cervical cord, involving the origin of 
the brachial plexus, the arms will be 
affected. Pupillarj^ changes are also 
frequently noted when the disease is 
of the cervical cord through implica- 
tion of Budge's ciliospinal center. 

Case characterized by an acute as- 
cending paralysis, commencing with 
indications of meningitis in the form 
of acute pain and spinal rigidity. 
Vision was impaired on the follow- 
ing day, and on the day after this 
evidence of slight papillitis, more on 
the right side, was observed. The 
upper limit of hyperesthesia was one 
inch below the nipples. On the ninth 
day of illness the breathing was al- 
most entirely abdominal, but the arms 



SPINAL CORD, DISEASES OF (PRITCHARD). 



233 



could be easily moved. On the four- 
teenth day marked dysphagia set in, 
and the patient died while attempting 
to swallow fluid. E. F. Clowes (Lan- 
cet, Mar. 23, 1912). 

Should the myelitis extend upward 
the functions of the vagus are dis- 
turbed and dyspnea, with circulatory 
and vasomotor symptoms, is added 
to the picture. Following- the irrita- 
tive come the paralytic symptoms. 
The hyperesthesia is succeeded by 
anesthesia, which is characteristically 
erratic in distribution. Any or all 
other forms of common sensation 
may be impaired or completely lost. 
There may be dissociation of sensa- 
tion. 

The motor weakness is succeeded 
by actual paralysis, which follows an 
anatomical distribution, but is usu- 
ally not absolute. This paralysis 
may be flaccid or spastic, or first one 
and later the other, with abolished or 
exaggerated reflexes according to the 
location of the lesion. Widespread 
motor and sensoiy paralysis may fol- 
low slowly a prolonged irritative 
stage or it may be extensive and com- 
plete in a few hours or days. Within 
a few weeks or months atrophy of the 
muscle, sometimes slight, sometimes 
extreme, occurs. The electrical reac- 
tions may remain normal, although 
both quantitative and qualitative 
changes have been frequently noted. 
Bed-sores are exceedingly common in 
severe cases, and are sometimes an 
extremely dangerous symptom. 

In the spastic cases decided con- 
tractures may develop, the knees be- 
ing flexed upon the abdomen, the 
heels touching the buttocks. Clonic 
or tonic spasms occurring in ex- 
quisitely painful paroxysms add to 
the sufferings of the patient in many 



instances. In the chronic variety of 
the disease the irritative symptoms 
are far less prominent. The mind re- 
mains unaffected in all cases except 
where an insanity may be superadded 
from pain and abject helplessness. It 
should be remembered, too, that the 
syphilis or tuberculosis or alcohol 
causing a myelitis may later attack 
the brain. 

Case of a man of 50 with a history 
of syphilis. He began to experience 
pain in the spine, and after a few 
days there was sudden and total 
paralysis of the legs, but no flaccid 
paralysis. The spine was painted 
with tincture of iodine, while vigor- 
ous mercurial treatment was insti- 
tuted and by the fifth day the man 
was taking a few steps and soon was 
able to return to business. Britto 
(Brazil Medico, Nov. 15, 1914). 

Case of myelitis in a child of 5^^ 
years, who had complained of vague 
pains in the chest and legs. There 
was paralysis of both legs and back 
with anesthesia extending from the 
toes to a line drawn around the chest 
just below the nipples. The tempera- 
ture, previously fairly normal, rose 
just before death. The heart and 
lungs remained normal. There was 
no history of any infectious fever, 
which is the rule in these cases. The 
etiology of this case is obscure. H. 
T. Ashby (Brit. Jour. Child. Dis.. 
May, 1915). 
DIAGNOSIS.— The acute disease 
may occasionally closely resemble 
Landry's paralysis. In the latter af- 
fection the sensory symptoms are 
slight ; usually there are no bladder 
or rectal symptoms, na girdle sensa- 
tion, and the course of the disease is. 
as a rule, much more rapid. Certain 
types of multiple neuritis are occa- 
sionally temporarily confusing. This 
is especially true of the cases of 
myelitis inducing flaccid paraplegia 
or diplegia. In such cases, however, 



234 



SPINAL CORD, DISEASES OF (PRITCHARD). 



pain is much less conspicuous than 
in neuritis, and in the latter the 
sphincters are not involved. Bed- 
sores and other trophic lesions are 
rare in neuritis. 

Spinal meningitis rarely exists alone, 
the cerebral meninges being usually 
simultaneously involved. In syph- 
ilitic or tubercular spinal pachymenin- 
gitis or leptomeningitis, the pain is 
usually much more conspicuous and 
the irritative spasms more decided. 
Usually, however, the cord is soon 
involved, and the differentiation is 
unimportant. 

Occasionally tabes is suggested. 
The knee-jerks may be abolished or 
greatly diminished, the genital func- 
tions are involved, the sensory symp- 
toms may be similar, Romberg's 
symptom may be present, and there 
may be an ataxic gait. The Argyll- 
Robertson pupil vvrill be found want- 
ing, however, as well as other ocular 
and optic-nerve changes ; the pains 
are different in character and degree, 
and there is true motor paralysis. 

The history as regards mode of 
onset and rate of progress is of value 
in differentiating spinal muscular atro- 
phy and amyotrophic lateral sclerosis 
and primary lateral sclerosis from my- 
elitis. Tumor of the cord is almost 
invariably complicated with myelitis 
of focal type, and the symptoms are 
necessarily identical in great meas- 
ure. It is possible, however, to de- 
termine the existence of tumor at 
times by the more intense and some- 
times agonizing pain, the slower rate 
of progress, the narrower limitation 
of symptoms, and the lessened degree 
of constitutional disturbance. The 
presence of tumor elsewhere, espe- 
cially if malignant, is often of assist- 
ance. The X-ray is of very infre- 



f|ucnt value in suspected cord tumor 
in my experience. Its employment is 
none the less indicated as a routine 
procedure in suspected cases. Spinal 
hemorrhage, if at all extensive, is 
usually quickly fatal from shock. 

Case in which the symptoms of the 
myelitis changed, showing that the 
lesion had migrated. Patient was a 
robust mechanical engineer of 30, 
who ran a rusty nail into one toe 
and a month later had to work in icy 
water all one night. The motor pa- 
ralysis, motor irritation, disturbances 
in sensibility and in the reflexes were 
at first those typical of myelitis in 
the lower spinal cord, but then these 
subsided and others developed indi- 
cating transference of the lesion to a 
region higher up. Among the most 
disturbing symptoms in the later 
phase were the unbearable itching 
from axillae to ears, including the 
arms, and also the headache. Inva- 
sion of the medulla oblongata was 
momentarily expected, but under in- 
tramuscular injections daily of 10 c.c. 
{lYi drams) camphorated oil, with 
strychnine and aspirin, a marked 
turn for the better was noted, and 
with continued galvanization, strych- 
nine injections and carbonated baths 
a clinical cure followed, even the 
cremaster and abdominal reflexes re- 
turning. In less than three months 
from the first symptoms the patient 
felt entirely well. Bing (Med. Klinik, 
Dec. 15, 1912). 

ETIOLOGY. — The disease may 
occur at any age and in either sex, 
though it is most common in males 
between the ages of 15 and 40 years. 
Prolonged or severe exposure to cold 
and dampness is a frequent and po- 
tent etiological factor. Next in fre- 
quency and importance, perhaps, is 
trauma, including excessive physicjd 
effort or exertion. 

Case of myelitis first manifesting 
itself two days after a severe fright 
from burglars; the patient had pre- 



SPINAL CORD, DISEASES OF (PRITCHARD). 



235 



viously suffered from an attack of 
facial paralysis from which he seemed 
to have perfectly recovered. The 
case terminated fatally, and necropsy 
showed extensive organic disease in 
the lumbar cord. Cases of paralysis 
from fright have usually been at- 
tributed to hysteria. The patient also 
suffered from perirectal infection, and 
septicemia was given as the cause of 
death. W. G. Spiller (Jour. Amer. 
Med. Assoc, Oct. 31, 1914). 

A relatively large number of cases 
are due to syphilis, which may act 
either directly or remotely as cause. 
Even in cases where an obvious 
trauma or other etiological factor is 
present, a Wassermann should be 
done as a matter of routine. The co- 
existence of syphilis may modify both 
prognosis and treatment in cases due 
to other exciting causes. 

Case in a girl of 17 with both gon- 
orrhea and syphilis; three months 
after the development of the syph- 
ilitic eruption she began to have 
fever, headache and paresis of the 
legs, blending into total paraplegia of 
the ascending type, fatal the fifteenth 
day. The findings in the spinal cord 
were those characteristic of acute 
poliomyelitis, but the symptoms had 
been more those of Landry's paral- 
ysis. A tetragenus in pure cultures 
was obtained from the blood and 
cerebrospinal fluid, and this germ 
was evidently responsible for the 
syndrome observed. Catola (PoH- 
clinico, Jan., Med. Sec, 1911). 

Tuberculous myelitis is rare, though 
spinal meningitis due to tuberculosis 
with secondary complicating invasion 
of the cord is not uncommon. Oc- 
casionally myelitis occurs during or 
immediately following (propter hoc) 
the acute infectious diseases. Ar- 
senic, lead, and other metallic poisons 
may induce the disease. 

A toxi-infectious myelitis may run 
an absolutely latent course, and be 



merely a necropsy surprise. In other 
cases, the only sign may be exag- 
geration of the foot and knee ten- 
don reflexes. This was found mani- 
fest in 60 of 100 typhoid patients, 
also in cases of pneumonia, miliary 
tuberculosis and neurasthenia. In 4 
cases of the latter, after influenza, 
this was the only spinal symptom. S. 
Bernheim (Revue de med., Jan., 
1912). 

Gross alcoholic excess is often a 
most important contributing factor 
and may occasionally prove the 
sole cause. In a very appreciable pro- 
portion of patients the etiology can- 
not be positively determined. This 
is especially true in subacute and 
chronic myelitis. 

Case of poliomyelitis in a young 
woman of 18 years, in whom grad- 
ually, over a period of three days, 
developed symptoms of a complete 
transverse myelitis involving about 
the middle of the dorsal cord. Im- 
provement was noticed on the sixth 
day, and recovery was pactically com- 
plete in about seven weeks. B. S. 
Sachs (Jour. Nerv. and Mental Dis., 
Nov., 1912). ■ 

Case in which at operation the 
cause of the compression was found 
to be a vertebral sequestrum, 3 cm. 
long, which had penetrated into the 
spinal canal and was surrounded by 
fibrous adhesions. The operation was 
followed by an excellent functional 
result. Mendler (Miinch. med. Woch., 
Nov. 5, 12, 19, 1912). 

PATHOLOGY.— The morbid an- 
atomy of myelitis varies with the 
cause of the disease somewhat and to 
a still greater degree with the stage 
during which death occurs. In pa- 
tients dying during the acute stages 
the apj)earance of the cord in the 
areas affected is that of an acute in- 
flammatory process. Punctiform or 
capillary hemorrhages are sometimes 
present. The cells are swollen and 



236 



SPINAL CORD, DISEASES OF (PRITCHARD). 



the nuclei distorted or displaced. 
These changes are followed by an 
increase of connective tissue, with 
destruction of the nerve-cells and 
nerve-fibers. The cord may be dis- 
colored and swollen in appearance on 
gross inspection or it may appear 
shrunken. Later the vessel-walls be- 
come thickened ; the nerve-tissue is 
more or less completely displaced by 
connective tissue; the cells disappear 
and are replaced by granular and 
amorphous material. The pia and 
even the dura may be involved. In 
some instances, especially those due 
to syphilis, the entire cord for sev- 
eral inches may be so softened as to 
be diffluent. The nerves may par- 
ticipate secondarily in the degenera- 
tive process. 

In most cases of acute myelitis, and 
also of acute poliomyelitis, the afifec- 
tion is caused, not by an inflamma- 
tion, but by thrombosis of some of 
the vessels of the spinal cord (where, 
in the latter disease, it is not due to a 
special acute degenerative process). 
This conclusion is rendered obvious 
by the similarity of the morbid 
changes in question to those occur- 
ring in the brain which are due to 
thrombosis, as well as to the absence 
of any reason why a primary inflam- 
mation should be rare in the brain 
and common in the spinal cord. Bas- 
tian (Lancet, Nov. 26, 1910). 

PROGNOSIS.— This varies widely 
in individual instances. Myelitis due 
to causes which are removable by 
surgical procedure — as, for example, 
compression from trauma, tumor, or 
vertebral disease — may occasionally 
be completely cured. Syphilitic mye- 
litis ofifers a distinctly better progno- 
sis than the non-syphilitic, although 
even here an opinion as to the outcome 
should always be extremely guarded. 
Immediate danger as regards life is 



greatest in myelitis due to or follow- 
ing the infectious fevers, sepsis, and 
severe injury. The duration of the 
disease is equally indefinite; a sub- 
acute myelitis may pass into a 
chronic, slowly progressive form, the 
gradual development of symptoms 
extending over a period of many 
months or years. The inflammation 
may subside after a varying length of 
time and be followed by a necrosis 
or sclerosis which is limited by the 
preceding inflammation, the patient 
being left with a paralysis which re- 
mains permanently stationary. The 
process may stop and then start up 
again, some slight additional cause 
relighting the fire in a locality pre- 
disposed by previous disease. The 
severity of the trophic symptoms is 
quite reliable as a guide in determin- 
ing the immediate danger to life, deep 
and extensive bed-sores being invari- 
ably of ill omen. Severe bladder 
symptoms are also of evil significance. 
TREATMENT.— Absolute rest in 
bed is essenial in all cases ; at first 
counterirritation should be employed, 
with extreme caution, on account of 
bed-sores. A water-bed is often ad- 
visable from the first to prevent this 
complication. The catheter should 
be employed also with extreme anti- 
septic and mechanical precaution. 
Pain should be relieved by opiates 
when necessary, but in minimum 
doses. In syphilitic myelitis the pa- 
tient should be put at once upon full 
and rapidly increasing doses of potas- 
sium iodide. The dose to begin should 
be at least 25 drops of the saturated 
solution. The salt should be pure 
and the vehicle should be changed 
every few days — water, milk, Vichy, 
Apollinaris, Giesshiibler water, or 
plain carbonated water may be em- 



SPINAL CORD, DISEASES OF (PRITCHARD). 



237 



ployed in turn. The dose should be 
progressively diluted more and more, 
as it is increased. Should iodism de- 
velop, double the dose if less than 40 
drops or grains ; if over 100, reduce 
it one-half and rapidly increase to a 
dose beyond that at which iodism oc- 
curred. 

The niaximum daily amount is 
to be determined by the effect on 
the disease, but it is rarely necessary 
to give more than 600 or 800 grains 
(40 or 53 Gm.) daily. 

Mercury is superior to the iodide 
only when primary syphilis has im- 
mediately or at least recently pre- 
ceded the myelitis, but both drugs 
should be used in every case, either 
alternately or in conjunction. The 
immediate gain from the use of neo- 
salvarsan should not be relied upon, 
l)Ut should be followed up with mer- 
cury promptly. 

Syphilitic meningomyelitis and en- 
cephalitis, or even gumma, should be 
most responsive to direct medica- 
tion by one of the methods of intra- 
spinal or subdural introduction. 

When the disease results from 
trauma or is due to tumor, abscess, 
or disease of the vertebrae, the ques- 
tion of operative interference should 
always be considered and decided 
promptly in order to prevent exten- 
sion and secondary softening. 

Symptomatic relief may often be 
obtained by appropriate operative 
treatment, and this is true even in 
tuberculous myelitis, where lumbar 
puncture with drainage at times 
greatly alleviates the patient's dis- 
tress. In myelitis due to infection 
there is no specific drug or plan of 
treatment. Sodium salicylate, small 
doses of mercury, or full doses of 
iron may be given in addition to the 



familiar local measures during the 
acute stage. Hexamethylenamine has 
come into vogue as a routine drug in 
all cases due to trauma or infection. 

For the chronic disease we may ex- 
pect a certain amount of benefit from 
galvanism and massage. (See Polio- 
myelitis) . Silver, arsenic, gold, phos- 
phorus, and ergot are all mentioned 
as therapeutic resources, but there is 
little, if any, evidence of specific bene- 
fit from either. A tentative course 
of treatment with potassium iodide 
should be given in all chronic cases. 

AMYOTROPHIC LATERAL 
SCLEROSIS. 

DEFINITION.— Amyotrophic lat- 
eral sclerosis is a disease character- 
ized essentially by the two symptoms 
of spastic rigidity and muscular 
atrophy. 

SYMPTOMS.— The clinical his- 
tory of the disease is quite constant. 
It begins very insidiously. Usually 
the earliest symptoms are referable to 
the disease in the anterior horns, and 
are similar to those of incipient pro- 
gressive spinal muscular atrophy : 
wasting of the thenar and hypothenar 
muscles, of the interossei or of the 
muscles of the arms or legs, almost 
always symmetrically, with or with- 
out tremor, which is rarely fibrillary, 
however. The degree of wasting may 
be slight, or it may be readily mis- 
taken at this stage for some form of 
progressive muscular atrophy. 

Within a few weeks or months, or, 
it may be, simultaneously, a sense of 
unusual fatigue upon exertion, with 
muscular stiffness and increasing 
difficulty in walking or in using the 
arms, due to the developing spastic 
rigidity, is noted, and the patient 
seeks advice. On examination, in 



238 



SPINAL CORD, DISEASES OF (PRITCHARD). 



addition to the atrophy, which is 
often more perceptible to touch than 
to vision, the liml)s will be found 
more or less rii^id and resistant to 
passive motion, giving the examiner 
a sensation as of bending a lead pipe. 
The knee-jerks and other deep re- 
flexes will be found markedly exag- 
gerated, and often early in the dis- 
ease, and always in the well-estab- 
lished disease, ankle-clonus and wrist- 
clonus are readily elicited. If the 
bulbar nuclei are involved, there may 
be wasting of the muscles of the face, 
with alteration in the expression and 
impairment of speech, respiration, 
deglutition, and cardiac action. 

A symptom of importance is the 
altered electrical reaction to both the 
faradic and galvanic currents. The 
muscles respond more and more 
feebly to faradism. Qualitative changes 
with the galvanic current are present 
early, and it is not uncommon to find 
decided alteration of the normal polar 
formula, with reaction of degenera- 
tion within a few weeks or months. 
In the late stages of the disease the 
atrophic symptoms may dominate the 
picture, the rigidity disappears, the 
reflexes are lost, and the victim is 
bedridden, but with unimpaired in- 
telligence. 

In some cases of amyotrophic lat- 
eral sclerosis, the symptoms and 
signs suggest nothing more than a 
progressive muscular atrophy of the 
Aran-Duchenne type, the sclerosis of 
the anterolateral columns, character- 
istic of amyotrophic lateral sclerosis, 
not being manifested in any very 
distinct symptoms. In the case re- 
ported by the authors, there v^^as 
noted, in addition to the Aran- 
Duchenne syndrome, merely a slight 
exaggeration of the tendon reflexes 
in the four limbs, a temporarily posi- 
tive Babinski, a few brief attacks of 



rigidity and pain at long intervals, 
and only at the last a trace of mus- 
cular contracture. Yet the patient 
died about twenty months after ad- 
mission, and the spinal cord showed 
a typical lateral sclerosis. Such a 
case demonstrates the importance of 
paying heed to even minor spinal 
signs in the diagnosis of amyotrophic 
lateral sclerosis. A. Gonnet and A. 
Grimaud (Lyon med., Apr. 19, 1914). 

DIAGNOSIS.— The diagnosis is a 
matter of no difhculty ordinarily. 
The picture is that of primary lateral 
sclerosis and progressive spinal mus- 
cular atrophy combined. From other 
forms of myelitis and sclerosis pre- 
senting one or both of these symp- 
toms, this disease is distinguished by 
the usual absence of sensory symp- 
toms and of sphincter involvement. 

ETIOLOGY.— It is not at all a 
common affection, is seen oftenest 
during middle adult life, and affects 
males chiefly. The etiology is not 
definitely understood, although trau- 
matism, exposure to extreme cold, 
and excessive physical exertion, if 
prolonged, are probable auxiliary fac- 
tors etiologically. 

Two cases in which amyotrophic 
sclerosis developed after an injury to 
the hand in 1 case, and after a severe 
strain, followed some months later 
by a fall, in the other. There is only 
a reasonable presumption of trauma 
as an etiological factor, definite proof 
being lacking. A. H. Woods (Jour. 
Amer. Med. Assoc, June 24, 1911). 

PATHOLOGY. — The pathology, 
on the contrary, is unusually well 
defined and constant. In the spinal 
cord the lesions are found in the an- 
terior horns and in the lateral and 
anterior pyramidal columns. In the 
anterior horns the lesions are prac- 
tically identical with those observed 
in chronic poliomyelitis. The so- 



SPINAL CORD, DISEASES OF (PRITCHARD). 



239 



called giant cells are either atrophied 
or destroyed altogether. In the motor 
tracts, both lateral and anterior, there 
is in all cases a well-marked sclerosis 
of these fibers, extending throughout 
their entire length, often into and be- 
yond the pons and occasionally even 
to the subcortical motor fibers of the 
Rolandic area itself. If the ponto- 
bulbar region is involved, the motor 
nuclei show degenerative atrophy ex- 
actly as do the cells of the anterior 
cornua. The peripheral nerves also 
imdergo degeneration, which is of 
the parenchymatous type. In the 
muscles the essential fibers are re- 
placed by connective tissue and fat, 
the alteration in color and consist- 
ency being often readily apparent. 

PROGNOSIS. — The prognosis is 
hopeless as to cure. Early helpless- 
ness is the rule, and death occurs 
within a few years, though a fatal 
termination may be delayed by an in- 
duced or spontaneous remission or 
arrest of progress. 

TREATMENT.— Our therapeutic 
efforts are limited by experience to 
purely palliative measures. Among 
these, rest, massage, electricity, and 
hydrotherapy are all of value. The 
victims of this disease should be con- 
sidered legitimate subjects for thera- 
peutic experiment. 

PRIMARY LATERAL SCLE- 
ROSIS. 

SYNONYMS.— Spastic spinal pa- 
ralysis; spastic paraplegia. 

DEFINITION.— It is a disease of 
gradual progressive onset assumed to 
be dependent upon a primary sclero- 
tic affection of the lateral pyramidal 
tracts or columns, with symptoms of 
motor paralysis of spastic type, ex- 
aggerated reflexes, clonus, and con- 
tractures. 



SYMPTOMS.— Spastic spinal pa- 
ralysis is always of gradual onset. It 
may begin as a stiffness in walking 
or in using the arms which gradually 
increases and suggests a condition of 
tonic spasm. The essential symptom 
is spastic contracture of the muscles 
of the extremities, particularly the 
flexors. 

The symptoms are most objectively 
conspicuous in the lower limbs, and 
the gait almost p'athognomonic, con- 
sisting of short, jerky, spasmodic, 
dragging steps, the patient being 
tilted forward on tip-toe. The act of 
walking will sometimes induce a 
clonus causing a series of heel-taps 
as the foot drags along the floor. 
Clonus is nearly always present in 
decided degree, and the deep reflexes 
— knee, wrist, ankle, elbow, and jaw 
— are invariably greatly exaggerated. 
There are no sensory or trophic 
symptoms, nor are the intracranial 
nerves or functions involved; but the 
bladder is often disturbed, the patient 
exhibiting what Seguin has termed 
"hasty micturition." Sexual func- 
tion may be indirectly lost. 

In an examination of 35 cases of 
spastic paralysis, the writer found 
both Babinski's and Bechterew's re- 
flexes present in 57.1 per cent., Ba- 
binski's alone in 25.7 per cent., Bech- 
terew's alone in 11.4 per cent., and 
both reflexes absent in 5.7 per cent. 
In 17 cases in which both reflexes 
were present, Bechterew's was pres- 
ent on one side only in 6. The 
cases in which Bechterew's reflex 
was positive, in spite of the absence 
of Babinski's, are of special interest. 
Nikitin (Berl. klin. Woch., Sept. 7, 
1908). 

Spastic paralysis may result from 
an apparent normal delivery. In some 
cases interference with the dressing 
or the bathing- of the infant may be 
the first evidence of an existing spias- 



240 



SPINAL CORD, DISEASES OF (PRITCHARD). 



tic paralysis. In other cases delayed 
functions of sitting and walking sug- 
gest it. Convulsions in infants, either 
immediately after or shortly after 
delivery, should make us suspicious 
of cerebral injury. The possibility of 
syphilis as the etiological factor 
must always be remembered. Where 
ophthalmoscopic examination reveals 
increased intracranial pressure, and 
where there is not a great amount of 
interference with the mentality of 
the patient, subtemporal decompres- 
sion, as described by Sharpe, should 
be performed. In the other cases, 
and in the after-treatment of cases 
operated on, massage, electricity, 
manipulation, supports, tenotomies, 
and muscle education usually offer 
relief. J. Grossman (N. Y. Med. 
Jour., Mar. 11, 1916). 

DIAGNOSIS.— In spite of the 
vagueness of the pathology, the clin- 
ical picture is very constant and strik- 
ing. Secondary lateral sclerosis from 
intracranial or basilar lesions is con- 
fusing only when such lesions are bi- 
lateral, and the presence in such cases 
of cranial-nerve involvement and of 
mental impairment will at once ex- 
clude the primary type. In myelitis 
with spastic contractures, the pres- 
ence, in addition, of sensory symp- 
toms, atrophy, rectal and vesical pa- 
ralysis, with bed-sores and other 
trophic lesions, will readily dififeren- 
tiate. In disseminated sclerosis the 
patient may exhibit a typical spastic 
gait, with contractures and exagger- 
ated reflexes, but the additional symp- 
toms of intention tremor, nystagmus, 
scanning speech, oculomotor palsies, 
and sensory disturbances are pe- 
culiar, in their associated presence, to 
multiple sclerosis alone. In amyo- 
trophic lateral sclerosis the marked 
and early atrophy is a distinguish- 
ing symptom. In progressive spastic 
ataxia, or ataxic paraplegia, the inco- 



ordination is sufficient to exclude the 
disease under consideration. In all 
instances, primary lateral sclerosis 
should be diagnosed only after most 
rigid exclusion of every other possi- 
bility, and particularly disseminated 
sclerosis in an anomalous or atypical 
form. 

ETIOLOGY.— The disease afifects 
adult males chiefly, usually in the de- 
cade between 25 and 35. It is not 
very common, and its etiology is 
not at all definitely known. It oc- 
curs at times in several members of 
a family and in such instances doubt- 
less is due to an embryonal defect. 

PATHOLOGY.— The pathological 
evidence in support of the assumption 
that a primary sclerosis of the lateral 
columns exists is so slight and in- 
definite as to have led to much 
skepticism. Morbid changes found 
post mortem have been strikingly 
inconstant. Tumor, hydromyelus, 
pachymeningitis, transverse myelitis, 
syringomyelitis, hydrocephalus, and 
several times disseminated sclerosis 
are among the many lesions which 
have been observed. 

Hip-joint disease in 2 cases of con- 
genital spastic paralysis. The special 
feature of the microscopic findings in 
both cases was the primary develop- 
mental defect in the cells of the 
motor zone in the brain, a hypoplasia 
of the ganglion cells. The pyramidal 
tracts were apparently intact in the 
second case. S. Miura (Jahrb. f. 
Kinderheilk., July, 1912). 

PROGNOSIS. — The disease may 
last many years, the general health 
remaining quite good. Recoveries 
are unknown. The victim of the dis- 
ease is sooner or later incapacitated 
for any and all forms of physical 
labor, though he may be able to em- 
ploy the hands and arms after walk- 



SPINAL CORD, DISEASES OF (PRITCHARD). 



241 



ing shall have become impossible. 
The mind is not afifected. 

TREATMENT.— Prolonged rest 

is of the first importance, and will at 
times result in decided amelioration 
of symptoms. The motor depres- 
sants — hyoscine, atropine, and coni- 
um — have all been successfully em- 
ployed for the temporary relief of the 
spasticity. Hydrotherapy also serves 
effectually the same purpose. 

Trial of thiosinamine sodium sali- 
cylate in a case of chronic sclerosis 
of several years' standing. The con- 
tractures and pain were much dimin- 
ished, there was less ataxia, and the 
power of walking returned. The in- 
jections must be made deeply under 
the skin. K. A. Grossmann (The 
Hospital, Dec. 5, 1908). 

Very severe and progressive case 
of spastic spinal paralysis in which 
there was no obtainable evidence of 
acquired syphilis. Patient was al- 
most absolutely helpless and bedrid- 
den, and had been treated by almost 
every method known. When seen, in 
July, 1911, he was put on ascending 
doses of potassium iodide, which 
were rapidly raised to the over- 
whelming dose of 1248 grains (83 
Gm.) in a single day. From this 
time the drug was continued in 
amounts of 375 grains (25 Gm.) three 
times daily, after which it was grad- 
ually reduced as improvement con- 
tinued. To this treatment there were 
added massage, passive movements, 
educational exercises, and forcible 
breaking of adhesions in the joints. 
On January 1, 1914, the patient was 
discharged entirely cured. C. L. 
Nichols (L. I. Med. Jour., Oct., 1914). 

Surgical measures have been re- 
sorted to for the relief of spasticity 
with considerable success. In resec- 
tion of the spinal roots, iirst pro- 
posed in 1905 in this country by 
Spiller, the technique devised by 
Forster is that most employed at the 



present time. The spastic contrac- 
tures are either mitigated or cured, 
but adjuvant measures are indispen- 
sable. 

Fifteen cases on record in which 
resection of the nerve-roots has been 
attempted, according to Forster's 
technique. Two of the patients died, 
both adults, one from infection and 
the other from operative shock. 
The other patients were remarkably 
benefited, being restored to active 
life after years of absolute and hope- 
less immobility. F. Rose (Semaine 
med., July 7, 1909). 

Forster's operation consists in di- 
vision of the posterior spinal roots 
for severe forms of spastic weakness, 
especially in cases of cerebral diple- 
gia, old hemiplegias, etc. The prin- 
ciple of the operation depends upon 
the fact that the spasticity is due to 
loss of inhibitory control from the 
higher centers. The operation con- 
sists essentially in the division of the 
paths to the affected groups of mus- 
cle, without producing either ataxia 
or anesthesia. It has been proven 
that anesthesia does not occur unless 
three consecutive posterior roots are 
divided; Forster recommends there- 
fore that no more than two should 
ever be divided. The selection of the 
roots depends upon careful anatom- 
ical study. The indications for the 
operation are: (1) The presence of 
such severe contracture as to make 
standing and walking impossible. (2) 
The occurrence of painful cramps in 
the affected limbs. Thus far better 
results have been obtained for affec- 
tions of the lower extremity than for 
the upper. The operation is prefer- 
ably done in two stages. At the first 
a laminectomy with proper exposure 
of the dura is done. At the second 
the dura is opened and the affected 
posterior roots are resected. The 
after-treatment is important and in- 
cludes correction of deformity by 
mechanical means, plastic operations 
to overcome organic contractures and 
exercises. Otto May (Lancet, June 
3, 1911). 

-16 



242 



SPINAL CORD, DISEASES OE (PRITCHARD). 



Fourteen cases of spastic paralysis 
treated liy section of posterior spinal 
nerve-roots, 1^ of them of Little's 
disease, while 11 were in the dorso- 
luml)ar region. There were 2 deaths, 
the remainint^ 12 patients being more 
or less imi)roved. There was cessa- 
tion of spasm in all cases imme- 
diately after operation. Hunkin (Am. 
Jour. Orthop. Surg., Oct., 1913). 

Unilateral laminectomy, introduced 
by A. S. Taylor, seems to afford 
greater room for the surgical treat- 
ment of all degenerated cord lesions. 
The severity of surgical resection 
of the spinal roots has led to the em- 
ployment of other surgical measures 
of a more conservative type. 

Transplantation of the muscles 
and tendons often proves surpris- 
ingly effectual. In the moderately 
serious cases improvement under op- 
erative and orthopedic measures is 
always notable. Redard (Annales de 
med. et chir. infantiles, Oct. 1, 1913). 
Three cases in which Stoffel's 
method of weakening the contracted 
muscle by severing certain of its 
nerve-fibers was tried. Balance be- 
tween the muscle and its antagonist 
is restored. The patients were 3 and 
12 years old, with Little's disease or 
paralysis from early encephalitis. In 
two of the children the results are 
highly satisfactory. Bundschuh (Beit, 
z. klin. Chir., Sept., 1913). 

Stoffel corrects talipes equinus by 
resecting a portion of the popliteal 
nerve. The electrode is used in dis- 
tinguishing the nerve bundles. For 
contracture of the hamstring muscles, 
he operates upon the sciatic nerve in 
the upper thigh. For adductor spasm 
one o